Provider Demographics
NPI:1679145742
Name:BEAUCHAMP, GRISSELLE (DRA)
Entity Type:Individual
Prefix:
First Name:GRISSELLE
Middle Name:
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:DRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER PLAZA #740
Mailing Address - Street 2:SUITE 213 AVE. HOSTOS
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1540
Mailing Address - Country:US
Mailing Address - Phone:787-444-1120
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER PLAZA #740
Practice Address - Street 2:SUITE 213 AVE. HOSTOS
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-1540
Practice Address - Country:US
Practice Address - Phone:787-444-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty