Provider Demographics
NPI:1154468825
Name:BEAUREGARD, THERESA MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5909 BELLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-3306
Mailing Address - Country:US
Mailing Address - Phone:586-291-1335
Mailing Address - Fax:586-412-4626
Practice Address - Street 1:50505 SCHOENHERR RD STE 120
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-710-2306
Practice Address - Fax:586-412-4626
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI26010002962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer