Provider Demographics
NPI:1881888089
Name:BEVIL, RODNEY GLEN
Entity type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:GLEN
Last Name:BEVIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 E MORADA LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2604
Mailing Address - Country:US
Mailing Address - Phone:209-607-8535
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN
Practice Address - Street 2:SUITE #125
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8251
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF50142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist