Provider Demographics
NPI:1184930117
Name:BEVERLY, WILLIAM TEMPLE (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TEMPLE
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-0871
Mailing Address - Country:US
Mailing Address - Phone:719-671-7793
Mailing Address - Fax:
Practice Address - Street 1:828 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-2315
Practice Address - Country:US
Practice Address - Phone:719-671-7793
Practice Address - Fax:877-359-1299
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04736641041S0200X
COCSW-15101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49330888Medicaid
CO701760OtherVALUE OPTIONS, MEDICAID