Provider Demographics
NPI:1477695559
Name:BEETON, THERESA ANNA (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ANNA
Last Name:BEETON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:ANNA
Other - Last Name:BEETON-CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:17719 DEVEAU CT
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3452
Mailing Address - Country:US
Mailing Address - Phone:540-338-6940
Mailing Address - Fax:703-771-7556
Practice Address - Street 1:215 LOUDOUN ST SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3115
Practice Address - Country:US
Practice Address - Phone:703-771-7555
Practice Address - Fax:703-777-7556
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040009101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA107638Medicare UPIN