Provider Demographics
NPI:1659170231
Name:BEVERLY, OTHA LAVONNE
Entity type:Individual
Prefix:
First Name:OTHA
Middle Name:LAVONNE
Last Name:BEVERLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 PALO VERDE AVE STE 251
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3322
Mailing Address - Country:US
Mailing Address - Phone:562-270-4833
Mailing Address - Fax:562-377-7961
Practice Address - Street 1:5150 CANDLEWOOD ST STE 22C
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1929
Practice Address - Country:US
Practice Address - Phone:562-270-4833
Practice Address - Fax:562-377-7961
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker