Provider Demographics
NPI:1124390448
Name:BEAL, CHARLOTTA ELYSE
Entity Type:Individual
Prefix:
First Name:CHARLOTTA
Middle Name:ELYSE
Last Name:BEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTA
Other - Middle Name:ELYSE
Other - Last Name:ASHLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11045 LANDSWALK DR
Mailing Address - Street 2:#115
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-3450
Mailing Address - Country:US
Mailing Address - Phone:281-989-2851
Mailing Address - Fax:
Practice Address - Street 1:11045 LANDSWALK DR
Practice Address - Street 2:#115
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-3450
Practice Address - Country:US
Practice Address - Phone:281-989-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6S6W5Q2171W00000X
TX15541150172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171W00000XOther Service ProvidersContractor