Provider Demographics
NPI:1134251036
Name:EAGAN BEVERLY, SUZANNE M (LMHC, BC-DMT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:EAGAN BEVERLY
Suffix:
Gender:F
Credentials:LMHC, BC-DMT
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:EAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:875 MASS AVE STE 25
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:781-790-6369
Mailing Address - Fax:
Practice Address - Street 1:875 MASS AVE STE 25
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:781-790-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7965101YM0800X
MABC-DMT 1060225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1060OtherAMERICAN DANCE MOVEMENT THERAPY ASSOCIATION