Provider Demographics
NPI:1720406028
Name:BEVIS, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BEVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:BLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1304 1ST AVENUE CIR NE
Mailing Address - Street 2:
Mailing Address - City:KASSON
Mailing Address - State:MN
Mailing Address - Zip Code:55944-1609
Mailing Address - Country:US
Mailing Address - Phone:507-456-6606
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00730101YM0800X, 103TC0700X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical