Provider Demographics
NPI:1154405868
Name:BEAVER, GARY REX (MA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:REX
Last Name:BEAVER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 TAFT ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4129
Mailing Address - Country:US
Mailing Address - Phone:612-781-0275
Mailing Address - Fax:
Practice Address - Street 1:199 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 306
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5831
Practice Address - Country:US
Practice Address - Phone:763-780-1520
Practice Address - Fax:763-780-2114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2584103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist