Provider Demographics
NPI:1083135131
Name:COLON RIVERA, BEAKIE JORELISSE (LCSWA, LCAS)
Entity Type:Individual
Prefix:
First Name:BEAKIE
Middle Name:JORELISSE
Last Name:COLON RIVERA
Suffix:
Gender:F
Credentials:LCSWA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9317 58TH AVENUE CT SW APT Q302
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-6104
Mailing Address - Country:US
Mailing Address - Phone:910-587-9432
Mailing Address - Fax:
Practice Address - Street 1:9317 58TH AVENUE CT SW APT Q302
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-6104
Practice Address - Country:US
Practice Address - Phone:910-587-9432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-23687101YA0400X
NCP0117511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP011715OtherNORTH CAROLINA LCSWA
NCLCAS-23687OtherNORTH CAROLINA LCAS