Provider Demographics
NPI:1891293106
Name:BEVERLY, DECRESE A
Entity type:Individual
Prefix:
First Name:DECRESE
Middle Name:A
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 WATERSTONE OAK WAY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-4045
Mailing Address - Country:US
Mailing Address - Phone:901-497-6234
Mailing Address - Fax:
Practice Address - Street 1:5405 FOX PLAZA DR # 108G
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115
Practice Address - Country:US
Practice Address - Phone:901-497-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1416950Medicaid