Provider Demographics
NPI:1124217542
Name:BEAVER, CONNIE SUE (MA)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:SUE
Last Name:BEAVER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 S STAPLES ST
Mailing Address - Street 2:SUITE #302
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2952
Mailing Address - Country:US
Mailing Address - Phone:361-992-1444
Mailing Address - Fax:361-992-1479
Practice Address - Street 1:6000 S STAPLES ST
Practice Address - Street 2:SUITE #302
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2952
Practice Address - Country:US
Practice Address - Phone:361-992-1444
Practice Address - Fax:361-992-1479
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health