Provider Demographics
NPI:1013100437
Name:BEAVERS, COLLEEN MARIE (MA, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARIE
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-2126
Mailing Address - Country:US
Mailing Address - Phone:217-429-1052
Mailing Address - Fax:217-423-7605
Practice Address - Street 1:2715 N 27TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2126
Practice Address - Country:US
Practice Address - Phone:217-429-1052
Practice Address - Fax:217-423-7605
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist