Provider Demographics
NPI:1225354087
Name:BEALL, BYRON FRANK (LCSW, BCBA)
Entity Type:Individual
Prefix:MR
First Name:BYRON
Middle Name:FRANK
Last Name:BEALL
Suffix:
Gender:M
Credentials:LCSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96100 HIDDEN MARSH LN
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1656
Mailing Address - Country:US
Mailing Address - Phone:904-556-2169
Mailing Address - Fax:
Practice Address - Street 1:96100 HIDDEN MARSH LN
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1656
Practice Address - Country:US
Practice Address - Phone:904-556-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1010451103K00000X
FL5260104100000X, 1041C0700X
FLSW52601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692499998OtherMEDICAID WAIVER
FL692499996OtherMEDICAID WAIVER