Provider Demographics
NPI:1558645473
Name:BEAULIEU, AMY A (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W DODDS ST STE 130
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3023
Mailing Address - Country:US
Mailing Address - Phone:812-269-8571
Mailing Address - Fax:
Practice Address - Street 1:223 W DODDS ST STE 130
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3023
Practice Address - Country:US
Practice Address - Phone:812-269-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006614A1041C0700X, 1041C0700X
MELC124751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical