Provider Demographics
NPI:1225065683
Name:MACAULEY, BETH (PHD, CCC-SLP, HPCS)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:MACAULEY
Suffix:
Gender:F
Credentials:PHD, CCC-SLP, HPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 RIVA RIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8222
Mailing Address - Country:US
Mailing Address - Phone:616-818-8934
Mailing Address - Fax:616-331-5556
Practice Address - Street 1:1764 RIVA RIDGE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8222
Practice Address - Country:US
Practice Address - Phone:616-818-8934
Practice Address - Fax:616-331-5556
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3174OtherOK LICENSE TO PRACTICE SL
01080764OtherASHA ACCOUNT NUMBER