Provider Demographics
NPI:1760464937
Name:BEAUDRY, HEATHER L (PHD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:BEAUDRY
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 1:1907 N ROAN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3182
Mailing Address - Country:US
Mailing Address - Phone:423-282-0164
Mailing Address - Fax:
Practice Address - Street 1:1907 N ROAN ST STE 207
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3182
Practice Address - Country:US
Practice Address - Phone:423-282-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA042017OtherBLUE SHIELD
PA092017Medicare ID - Type Unspecified
PA042017OtherBLUE SHIELD