Provider Demographics
NPI:1689823973
Name:STEWART R. BEASLEY JR. PH.D. LLC
Entity Type:Organization
Organization Name:STEWART R. BEASLEY JR. PH.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:R
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-341-4313
Mailing Address - Street 1:1366 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5029
Mailing Address - Country:US
Mailing Address - Phone:405-341-4313
Mailing Address - Fax:405-340-4567
Practice Address - Street 1:1366 E 15TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5029
Practice Address - Country:US
Practice Address - Phone:405-341-4313
Practice Address - Fax:405-340-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK199103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty