Provider Demographics
NPI:1881679975
Name:BEAVER, ERIK DMITRI (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIK
Middle Name:DMITRI
Last Name:BEAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3334
Practice Address - Country:US
Practice Address - Phone:920-262-4800
Practice Address - Fax:920-262-4813
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1882103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39649500Medicaid
WI39649500Medicaid