Provider Demographics
NPI:1720209307
Name:GIBBS-CASSADY, BEVERLEE J (EDD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLEE
Middle Name:J
Last Name:GIBBS-CASSADY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 N KENDRICK ST STE 3
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1598
Mailing Address - Country:US
Mailing Address - Phone:928-774-7778
Mailing Address - Fax:928-913-0891
Practice Address - Street 1:416 N KENDRICK ST STE 3
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1598
Practice Address - Country:US
Practice Address - Phone:928-774-7778
Practice Address - Fax:928-913-0891
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3410103TS0200X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical