Provider Demographics
NPI:1811521859
Name:BEAVERS, MELONIE DIANE
Entity type:Individual
Prefix:
First Name:MELONIE
Middle Name:DIANE
Last Name:BEAVERS
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:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:JOLO
Mailing Address - State:WV
Mailing Address - Zip Code:24850-0116
Mailing Address - Country:US
Mailing Address - Phone:304-890-3005
Mailing Address - Fax:
Practice Address - Street 1:5240 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2122
Practice Address - Country:US
Practice Address - Phone:304-926-2300
Practice Address - Fax:304-926-2304
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2479101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional