Provider Demographics
NPI:1598181588
Name:BEACH, ANDREA MICHELLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:BEACH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E FERGUSON ST
Mailing Address - Street 2:SUITE 1204
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5759
Mailing Address - Country:US
Mailing Address - Phone:903-526-5709
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST
Practice Address - Street 2:SUITE 1204
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5759
Practice Address - Country:US
Practice Address - Phone:903-526-5709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104684OtherSTATE LICENSE