Provider Demographics
NPI:1114079761
Name:REARDON, BEA (MSW)
Entity Type:Individual
Prefix:MS
First Name:BEA
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01966
Mailing Address - Country:US
Mailing Address - Phone:978-282-0990
Mailing Address - Fax:978-282-0990
Practice Address - Street 1:19 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930
Practice Address - Country:US
Practice Address - Phone:978-282-0990
Practice Address - Fax:978-282-0990
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1064921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAREP21199Medicare ID - Type Unspecified