Provider Demographics
NPI:1336263656
Name:MICHAEL, BEVERLY (LISW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 MESA BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3038
Mailing Address - Country:US
Mailing Address - Phone:505-980-0886
Mailing Address - Fax:
Practice Address - Street 1:1109 MESA BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-3038
Practice Address - Country:US
Practice Address - Phone:505-980-0886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-06355101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24331350Medicaid