Provider Demographics
NPI:1427180397
Name:BEAUDREAU, THERESA A (LICSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:BEAUDREAU
Suffix:
Gender:F
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:PO BOX 8879
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-0879
Mailing Address - Country:US
Mailing Address - Phone:401-572-3120
Mailing Address - Fax:401-572-3351
Practice Address - Street 1:291 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5130
Practice Address - Country:US
Practice Address - Phone:401-274-9231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI005021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2785OtherBLUECROSS BLUESHIELD
6254399OtherUNITED HEALTH
298567000OtherMAGELLAN
RITB63105Medicaid
1036990OtherNEIGHBORHOOD HEALTH
RI408805OtherBLUECHIP
6254399OtherUNITED HEALTH