Provider Demographics
NPI:1043264914
Name:HARRISON-BEAUREGARD, KATHLEEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:HARRISON-BEAUREGARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 FAUNCE CORNER RD
Mailing Address - Street 2:UNIT 110
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1262
Mailing Address - Country:US
Mailing Address - Phone:508-994-1109
Mailing Address - Fax:508-994-1129
Practice Address - Street 1:92 FAUNCE CORNER RD
Practice Address - Street 2:UNIT 110
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1262
Practice Address - Country:US
Practice Address - Phone:508-994-1109
Practice Address - Fax:508-994-1129
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2106011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23727Medicare ID - Type Unspecified