1477512861 NPI number — DR. BERNADETTE CYNTHIA BEASLEY PSY. D.

Table of content: DR. BERNADETTE CYNTHIA BEASLEY PSY. D. (NPI 1477512861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477512861 NPI number — DR. BERNADETTE CYNTHIA BEASLEY PSY. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEASLEY
Provider First Name:
BERNADETTE
Provider Middle Name:
CYNTHIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY. D.
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:
1477512861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
933 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTESON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60443-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-748-2831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18141 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
HOMEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60430-2238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-922-3530
Provider Business Practice Location Address Fax Number:
708-922-3531
Provider Enumeration Date:
03/22/2006

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: 103TC0700X , with the licence number:  071006734 , 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: 01634900 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 198803101304 . This is a "HUMANA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com