Provider Demographics
NPI:1386880458
Name:IGO, BEVERLY JEAN (MDIV,, MA)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:JEAN
Last Name:IGO
Suffix:
Gender:F
Credentials:MDIV,, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 HITCHING POST VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-1112
Mailing Address - Country:US
Mailing Address - Phone:719-578-0432
Mailing Address - Fax:
Practice Address - Street 1:6208 LEHMAN DR
Practice Address - Street 2:SUITE 106
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8408
Practice Address - Country:US
Practice Address - Phone:719-578-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1275101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health