Provider Demographics
NPI:1386893436
Name:BEATY, GWENEVERE (LISW-CP)
Entity type:Individual
Prefix:MS
First Name:GWENEVERE
Middle Name:
Last Name:BEATY
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 DAPHINE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2009
Mailing Address - Country:US
Mailing Address - Phone:919-643-7693
Mailing Address - Fax:919-543-7693
Practice Address - Street 1:107 DAPHINE DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2009
Practice Address - Country:US
Practice Address - Phone:919-643-7693
Practice Address - Fax:919-543-7693
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-13
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical