Provider Demographics
NPI:1720703465
Name:BEVAN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BEVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 NECTAR RUN
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969-2183
Mailing Address - Country:US
Mailing Address - Phone:267-614-4268
Mailing Address - Fax:
Practice Address - Street 1:169 NECTAR RUN
Practice Address - Street 2:
Practice Address - City:TELFORD
Practice Address - State:PA
Practice Address - Zip Code:18969-2183
Practice Address - Country:US
Practice Address - Phone:267-614-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC015625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist