Provider Demographics
NPI:1073711628
Name:BELLEAU, G WAYNE (HIS)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:WAYNE
Last Name:BELLEAU
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DREW LN
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-6216
Mailing Address - Country:US
Mailing Address - Phone:508-539-8086
Mailing Address - Fax:
Practice Address - Street 1:10 CORDAGE PARK CIR
Practice Address - Street 2:SUITE 239
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7318
Practice Address - Country:US
Practice Address - Phone:508-747-2233
Practice Address - Fax:508-747-7919
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1534882Medicaid