Provider Demographics
NPI:1992375802
Name:CHAMBERS, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CLOVER ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5218
Mailing Address - Country:US
Mailing Address - Phone:860-807-6971
Mailing Address - Fax:
Practice Address - Street 1:3 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CENTERBROOK
Practice Address - State:CT
Practice Address - Zip Code:06409-1089
Practice Address - Country:US
Practice Address - Phone:860-532-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional