Provider Demographics
NPI:1578999041
Name:BEACH, BONNY MARGUERITE (LISAC)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:MARGUERITE
Last Name:BEACH
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 N 2ND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3027
Mailing Address - Country:US
Mailing Address - Phone:602-448-0935
Mailing Address - Fax:602-532-7202
Practice Address - Street 1:1648 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-5340
Practice Address - Country:US
Practice Address - Phone:602-448-0935
Practice Address - Fax:602-532-7202
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC 11484101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor