Provider Demographics
NPI:1205845286
Name:BEAVER, NOVELLA S (LCSW)
Entity type:Individual
Prefix:
First Name:NOVELLA
Middle Name:S
Last Name:BEAVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 INDUSTRIAL PKWY
Mailing Address - Street 2:PO BOX 1478
Mailing Address - City:CLARKSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23927-3140
Mailing Address - Country:US
Mailing Address - Phone:434-575-6738
Mailing Address - Fax:434-374-3321
Practice Address - Street 1:424 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5200
Practice Address - Country:US
Practice Address - Phone:434-572-2936
Practice Address - Fax:434-572-4665
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040016321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010390419Medicaid
R60334Medicare UPIN