Provider Demographics
NPI:1184760217
Name:BEAVEN, REINA (OTR-L)
Entity type:Individual
Prefix:
First Name:REINA
Middle Name:
Last Name:BEAVEN
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 SILVER GLADE TRL
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-1784
Mailing Address - Country:US
Mailing Address - Phone:859-200-0886
Mailing Address - Fax:
Practice Address - Street 1:4308 SILVER GLADE TRL
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1784
Practice Address - Country:US
Practice Address - Phone:859-200-0886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003910A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200732820-AMedicare ID - Type UnspecifiedOCCUPATIONAL THERAPY