Provider Demographics
NPI:1194792226
Name:BEVIS, JUDITH ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ANNE
Last Name:BEVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SOUTH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-3282
Mailing Address - Country:US
Mailing Address - Phone:781-599-6582
Mailing Address - Fax:
Practice Address - Street 1:40 SOUTH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-3282
Practice Address - Country:US
Practice Address - Phone:781-599-6582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4250103TC0700X, 103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0520217Medicaid
R84501Medicare UPIN
MA0520217Medicaid