Provider Demographics
NPI:1205180080
Name:GARRETT, BEVERLY JANE (MS PCC-S)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JANE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MS PCC-S
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:JANE
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS LPCC
Mailing Address - Street 1:2200 GRANDE BLVD SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1695
Mailing Address - Country:US
Mailing Address - Phone:937-266-3933
Mailing Address - Fax:
Practice Address - Street 1:2200 GRANDE BLVD SE
Practice Address - Street 2:SUITE B
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1695
Practice Address - Country:US
Practice Address - Phone:937-266-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE 0500587 SUPV101Y00000X
NM0157251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor