1003969106 NPI number — DEBORAH RUTH BEATTY M.S., L.C.P.C.

Table of content: LORI PETERSON L.M.P (NPI 1750673810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003969106 NPI number — DEBORAH RUTH BEATTY M.S., L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEATTY
Provider First Name:
DEBORAH
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., L.C.P.C.
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:
1003969106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3018 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODRIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60517-1351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-852-0133
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2777 FINLEY RD
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
DOWNERS GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60515-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-342-9941
Provider Business Practice Location Address Fax Number:
630-932-7639
Provider Enumeration Date:
01/19/2007

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: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02232279 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 229471 . This is a "COMPSYCH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0007871347 . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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