Provider Demographics
NPI:1962464735
Name:BEAVER, MICHAEL P (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:BEAVER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2367 STATE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:503-540-3442
Mailing Address - Fax:503-540-4097
Practice Address - Street 1:2367 STATE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:503-540-3442
Practice Address - Fax:503-540-4097
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR01182Medicare ID - Type Unspecified
OR0000TLBHFMedicare PIN