Provider Demographics
NPI:1366117871
Name:BEAVEN, MARY E (LSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BEAVEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:DAIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 SWAN LN
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-1215
Mailing Address - Country:US
Mailing Address - Phone:703-626-3434
Mailing Address - Fax:
Practice Address - Street 1:125 OLDE GREENWICH DR STE 300
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4008
Practice Address - Country:US
Practice Address - Phone:540-374-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040104301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical