Provider Demographics
NPI:1841598059
Name:BEVERLEE GIBBS-CASSADY
Entity Type:Organization
Organization Name:BEVERLEE GIBBS-CASSADY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBBS-CASSADY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:928-774-7778
Mailing Address - Street 1:416 N KENDRICK ST
Mailing Address - Street 2:SUITE 3
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
Practice Address - Street 2:SUITE 3
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3410103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ124554Medicare PIN