Provider Demographics
NPI:1598819229
Name:BEASLEY, TAMARA O (CCC,SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:O
Last Name:BEASLEY
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 1:2809 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3803
Mailing Address - Country:US
Mailing Address - Phone:910-867-0169
Mailing Address - Fax:
Practice Address - Street 1:3637 SYCAMORE DAIRY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3415
Practice Address - Country:US
Practice Address - Phone:910-487-1832
Practice Address - Fax:910-487-6950
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211258Medicaid
NC7412318Medicaid
NC013X1OtherGROUP PROVIDER #
NC1397HOtherBCBS INDIV PROV #