Provider Demographics
NPI:1336781319
Name:OSBORNE, BEVERLY S (MSW,ACSW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:S
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:MSW,ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 HOMBACH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781-1735
Mailing Address - Country:US
Mailing Address - Phone:906-643-9150
Mailing Address - Fax:
Practice Address - Street 1:799 HOMBACH ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1735
Practice Address - Country:US
Practice Address - Phone:906-643-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010612111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI216885OtherPPO