1427180397 NPI number — THERESA A BEAUDREAU LICSW

Table of content: THERESA A BEAUDREAU LICSW (NPI 1427180397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427180397 NPI number — THERESA A BEAUDREAU LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUDREAU
Provider First Name:
THERESA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427180397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8879
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02920-0879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-572-3120
Provider Business Mailing Address Fax Number:
401-572-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
291 WATERMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02906-5130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-274-9231
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  00502 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2785 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 6254399 . This is a "UNITED HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 298567000 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: TB63105 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1036990 . This is a "NEIGHBORHOOD HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 408805 . This is a "BLUECHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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