Provider Demographics
NPI:1891137873
Name:JOHNSON, BEVERLY C (MSW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 EDWARD AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762
Mailing Address - Country:US
Mailing Address - Phone:662-719-2005
Mailing Address - Fax:
Practice Address - Street 1:116 S EDWARD AVENUE
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762
Practice Address - Country:US
Practice Address - Phone:662-719-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS68NHC251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based