Provider Demographics
NPI:1518016492
Name:BEASLEY, SHEPHERD LEE (CPED)
Entity Type:Individual
Prefix:
First Name:SHEPHERD
Middle Name:LEE
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 SANTA BARBARA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-4394
Mailing Address - Country:US
Mailing Address - Phone:239-458-3360
Mailing Address - Fax:239-242-1095
Practice Address - Street 1:2311 SANTA BARBARA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-4394
Practice Address - Country:US
Practice Address - Phone:239-458-3360
Practice Address - Fax:239-242-1095
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED129225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter