Provider Demographics
NPI:1932555463
Name:LEWIS, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:LEWIS
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 1:2320 W PEORIA AVE
Mailing Address - Street 2:SUITE B147
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4753
Mailing Address - Country:US
Mailing Address - Phone:602-283-7117
Mailing Address - Fax:602-896-2580
Practice Address - Street 1:27 W RED MESA TRL
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-6228
Practice Address - Country:US
Practice Address - Phone:480-579-6590
Practice Address - Fax:602-896-2580
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4850385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child