Provider Demographics
NPI:1598703126
Name:BEVILL, LISA F (MCD,CCC-A)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:F
Last Name:BEVILL
Suffix:
Gender:F
Credentials:MCD,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3202
Mailing Address - Country:US
Mailing Address - Phone:478-743-8953
Mailing Address - Fax:478-743-1963
Practice Address - Street 1:540 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3202
Practice Address - Country:US
Practice Address - Phone:478-743-8953
Practice Address - Fax:478-743-1963
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
GA231HA2400X, 231HA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000767214AMedicaid
GA64PCBHCMedicare PIN