Provider Demographics
NPI:1992221600
Name:BEVERLY, SONIA DIANE
Entity Type:Individual
Prefix:MISS
First Name:SONIA
Middle Name:DIANE
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SONIA
Other - Middle Name:DIANE
Other - Last Name:MCCANTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 W FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4145
Mailing Address - Country:US
Mailing Address - Phone:704-865-4525
Mailing Address - Fax:
Practice Address - Street 1:175 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4145
Practice Address - Country:US
Practice Address - Phone:704-865-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0116961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical