Provider Demographics
NPI:1083775910
Name:BEAUCHAMP, BRENDA LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 666
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627
Mailing Address - Country:US
Mailing Address - Phone:787-820-2879
Mailing Address - Fax:787-820-2879
Practice Address - Street 1:CARR.#2 KM.93.0 BARRIO MEMBRILLO
Practice Address - Street 2:
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627
Practice Address - Country:US
Practice Address - Phone:787-820-2879
Practice Address - Fax:787-820-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1887103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent