Provider Demographics
NPI:1376970582
Name:BEAUREGARD, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVANS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29482-8650
Mailing Address - Country:US
Mailing Address - Phone:303-588-9511
Mailing Address - Fax:
Practice Address - Street 1:3203 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:SULLIVANS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29482-8650
Practice Address - Country:US
Practice Address - Phone:303-588-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1588615918Medicaid