Provider Demographics
NPI:1760688097
Name:BEAUREGARD, STEPHANIE LAINE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAINE
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 1:10533 GREENE DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-3540
Mailing Address - Country:US
Mailing Address - Phone:832-385-4304
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FT. BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-3231
Practice Address - Country:US
Practice Address - Phone:703-806-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052042512251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology