Provider Demographics
NPI:1740373000
Name:SUPLER, BEVERLY L (PHD)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:L
Last Name:SUPLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11825 ROCK LANDING DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4236
Mailing Address - Country:US
Mailing Address - Phone:757-873-1736
Mailing Address - Fax:757-873-1028
Practice Address - Street 1:11825 ROCK LANDING DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4236
Practice Address - Country:US
Practice Address - Phone:757-873-1736
Practice Address - Fax:757-873-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002835101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005-40-8962Medicaid