Provider Demographics
NPI:1215328018
Name:BEVERIDGE, LAURA (ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BEVERIDGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 STREETT CIR
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-3070
Mailing Address - Country:US
Mailing Address - Phone:443-617-3205
Mailing Address - Fax:
Practice Address - Street 1:339 STREETT CIR
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-3070
Practice Address - Country:US
Practice Address - Phone:443-617-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-15
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00006192255A2300X
DEJ3-00005482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer