Provider Demographics
NPI:1083048938
Name:BEAUDOIN, RICHARD L (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:BEAUDOIN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49920-1827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 4TH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1827
Practice Address - Country:US
Practice Address - Phone:906-284-1782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1245824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist