Provider Demographics
NPI:1679518153
Name:BEVAN, MARLENE A (PHD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:A
Last Name:BEVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 MUNSON AVE
Mailing Address - Street 2:STE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3638
Mailing Address - Country:US
Mailing Address - Phone:231-938-3111
Mailing Address - Fax:
Practice Address - Street 1:872 MUNSON AVE STE D
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3638
Practice Address - Country:US
Practice Address - Phone:231-238-3111
Practice Address - Fax:231-238-3214
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI231H00000X
237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540B802900OtherBLUE CROSS BLUE SHIELD
MI640B827240OtherBLUE CROSS BLUE SHIELD
MI804707456Medicaid
MI804707465Medicaid
MI903380558Medicaid
MI902575198Medicaid
MI804707447Medicaid