Provider Demographics
NPI:1770170219
Name:BEVERWYK-ABOUDA, TANA ELIZABETH (CPT, EIM)
Entity type:Individual
Prefix:MS
First Name:TANA
Middle Name:ELIZABETH
Last Name:BEVERWYK-ABOUDA
Suffix:
Gender:F
Credentials:CPT, EIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33-A SANTA FE COUNTY ROAD 119-N
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506
Mailing Address - Country:US
Mailing Address - Phone:505-927-8516
Mailing Address - Fax:
Practice Address - Street 1:628 N RIVERSIDE DR STE C
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2620
Practice Address - Country:US
Practice Address - Phone:505-927-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7987842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer