Provider Demographics
NPI:1649421421
Name:BEASLEY, NICOLE (PHD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 TAYLOR BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523
Mailing Address - Country:US
Mailing Address - Phone:925-685-9463
Mailing Address - Fax:925-685-9682
Practice Address - Street 1:399 TAYLOR BLVD
Practice Address - Street 2:STE 210
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:925-685-9463
Practice Address - Fax:925-685-9682
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19178103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical