Provider Demographics
NPI:1861076614
Name:THEODORE, BEVERLEY V (LPC)
Entity type:Individual
Prefix:
First Name:BEVERLEY
Middle Name:V
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 HARRIS TRAIL RD APT 4H
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-4250
Mailing Address - Country:US
Mailing Address - Phone:404-944-0525
Mailing Address - Fax:
Practice Address - Street 1:505 HARRIS TRAIL RD APT 4H
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-4250
Practice Address - Country:US
Practice Address - Phone:404-944-0525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty