Provider Demographics
NPI:1205940509
Name:KNIGHTEN, BEVERLY (LCSW)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:KNIGHTEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 ELK DR
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7606
Mailing Address - Country:US
Mailing Address - Phone:229-584-2540
Mailing Address - Fax:229-226-2036
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4950104100000X
GACSW0059141041C0700X
OK71171041C0700X
AR2283-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4950OtherMASTER SOCIAL WORKER
AR2283-COtherLCSW