Provider Demographics
NPI:1992780449
Name:FAIRHURST, BEVERLY (MA, LCMHC, LCDP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:FAIRHURST
Suffix:
Gender:F
Credentials:MA, LCMHC, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ROCCO AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5822
Mailing Address - Country:US
Mailing Address - Phone:401-725-2278
Mailing Address - Fax:
Practice Address - Street 1:610 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915-1504
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:401-435-7486
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00027101YA0400X
RI80101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406396OtherBLUE CHIP
RIBF15322Medicaid
RI30016-6OtherBLUE CROSS
RI62-34366OtherUNITED