Provider Demographics
NPI:1093572679
Name:BEAUREGARD CREATIVE ARTS THERAPY PLLC
Entity Type:Organization
Organization Name:BEAUREGARD CREATIVE ARTS THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUREGARD
Authorized Official - Suffix:
Authorized Official - Credentials:RDT/BCT, LCAT
Authorized Official - Phone:917-204-2846
Mailing Address - Street 1:135 COFFEY ST APT 206C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-1055
Mailing Address - Country:US
Mailing Address - Phone:917-204-2846
Mailing Address - Fax:
Practice Address - Street 1:225 BROADWAY STE 2130
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3733
Practice Address - Country:US
Practice Address - Phone:917-204-2846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty