Provider Demographics
NPI:1023357175
Name:THE BEACON CLINIC, PLLC
Entity Type:Organization
Organization Name:THE BEACON CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIBBEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-805-1752
Mailing Address - Street 1:790 CLEVELAND AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-3858
Mailing Address - Country:US
Mailing Address - Phone:651-805-1752
Mailing Address - Fax:
Practice Address - Street 1:790 CLEVELAND AVE S
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3858
Practice Address - Country:US
Practice Address - Phone:651-805-1752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-10
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty