Provider Demographics
NPI:1568803682
Name:CROSS, BEVERLY DIANNE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:DIANNE
Last Name:CROSS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:BEVERLY
Other - Middle Name:DIANNE
Other - Last Name:WISOTSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2535 TOWNSGATE RD
Mailing Address - Street 2:209
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5965
Mailing Address - Country:US
Mailing Address - Phone:805-379-1009
Mailing Address - Fax:
Practice Address - Street 1:2535 TOWNSGATE RD
Practice Address - Street 2:209
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5965
Practice Address - Country:US
Practice Address - Phone:805-379-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMQ17269106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist