Provider Demographics
NPI:1386462299
Name:BEVERLEY, SAMANTHA (DT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BEVERLEY
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1704
Mailing Address - Country:US
Mailing Address - Phone:815-708-5829
Mailing Address - Fax:618-503-0263
Practice Address - Street 1:4501 HILL RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-3519
Practice Address - Country:US
Practice Address - Phone:618-830-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist