Provider Demographics
NPI:1306396494
Name:BEAUDRY, KEVIN MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MARK
Last Name:BEAUDRY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1019
Mailing Address - Country:US
Mailing Address - Phone:134-342-2634
Mailing Address - Fax:
Practice Address - Street 1:403 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1019
Practice Address - Country:US
Practice Address - Phone:413-342-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1221991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical