Provider Demographics
NPI:1073562542
Name:BEACH, THERESA MARIE (LCSW R)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:BEACH
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1021
Mailing Address - Country:US
Mailing Address - Phone:585-394-1294
Mailing Address - Fax:585-394-1294
Practice Address - Street 1:527 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1021
Practice Address - Country:US
Practice Address - Phone:585-394-1294
Practice Address - Fax:585-394-1294
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR044998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY338407OtherMVP VALUE OPTIONS
NYP010044998OtherBLUE CROSS BLUE SHIELD
NYP010044998OtherBLUE CROSS BLUE SHIELD