Provider Demographics
NPI:1417133091
Name:BEAULIEU, CYNTHIA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:L
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-3830
Mailing Address - Fax:614-293-4870
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1229
Practice Address - Country:US
Practice Address - Phone:614-293-3830
Practice Address - Fax:614-293-4870
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4192103T00000X
OHP.07870103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0419108Medicaid