Provider Demographics
NPI:1619185469
Name:BEAZLEY, JONATHAN C (LMFT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:C
Last Name:BEAZLEY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 MERROW RD STE D
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3957
Mailing Address - Country:US
Mailing Address - Phone:860-875-2578
Mailing Address - Fax:
Practice Address - Street 1:384 MERROW RD STE D
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3957
Practice Address - Country:US
Practice Address - Phone:860-875-2578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000631106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410000631CT02OtherANTHEM BLUE CROSS