Provider Demographics
NPI:1295896405
Name:HARRIS, BEVERLY DAWN (MSW, PLCSW)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:DAWN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSW, PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 E LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-2293
Mailing Address - Country:US
Mailing Address - Phone:417-459-2969
Mailing Address - Fax:
Practice Address - Street 1:2715 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-2293
Practice Address - Country:US
Practice Address - Phone:417-459-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060225911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO491031100Medicaid