Provider Demographics
NPI:1730694498
Name:TRAIL, BEVONNA (LCSW)
Entity type:Individual
Prefix:
First Name:BEVONNA
Middle Name:
Last Name:TRAIL
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 1:3957 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE 201 PMB1065
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092
Mailing Address - Country:US
Mailing Address - Phone:470-588-2692
Mailing Address - Fax:
Practice Address - Street 1:3957 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 201 PMB1065
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:470-588-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0965471041C0700X
GACSW0084931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical