Provider Demographics
NPI:1730295015
Name:BEAUREGARD, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CASSEEKEE TRL
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3354
Mailing Address - Country:US
Mailing Address - Phone:321-837-0961
Mailing Address - Fax:
Practice Address - Street 1:5200 BABCOCK ST NE
Practice Address - Street 2:STE 401
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4612
Practice Address - Country:US
Practice Address - Phone:321-984-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT20371OtherLICENSE