Provider Demographics
NPI:1760584676
Name:DAZO, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:DAZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S MORRISON RD APT 63
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4011
Mailing Address - Country:US
Mailing Address - Phone:812-620-3883
Mailing Address - Fax:
Practice Address - Street 1:5980 W 71ST ST STE 201
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1785
Practice Address - Country:US
Practice Address - Phone:317-388-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008389A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist