Provider Demographics
NPI:1629257811
Name:BEVENS, MELODY ANN (MFT)
Entity Type:Individual
Prefix:MS
First Name:MELODY
Middle Name:ANN
Last Name:BEVENS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 MANZANITA PARK RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223
Mailing Address - Country:US
Mailing Address - Phone:951-845-3155
Mailing Address - Fax:951-845-8412
Practice Address - Street 1:14700 MANZANITA PARK ROAD
Practice Address - Street 2:NONE
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-0247
Practice Address - Country:US
Practice Address - Phone:951-845-3155
Practice Address - Fax:951-845-8412
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 24287106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist