Provider Demographics
NPI:1164064622
Name:BEAUDRE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BEAUDRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-2155
Mailing Address - Country:US
Mailing Address - Phone:586-819-1888
Mailing Address - Fax:
Practice Address - Street 1:22170 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6007
Practice Address - Country:US
Practice Address - Phone:248-372-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator