Provider Demographics
NPI:1770646762
Name:BEAUCHAMP, ELLEN LOUISE (PHD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LOUISE
Last Name:BEAUCHAMP
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 1:10047 MAIN ST APT 310
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5317
Mailing Address - Country:US
Mailing Address - Phone:425-269-1218
Mailing Address - Fax:
Practice Address - Street 1:10047 MAIN ST APT 310
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5317
Practice Address - Country:US
Practice Address - Phone:425-269-1218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103T00000X
DCPSY1418103T00000X
IDPSY202216103T00000X
COPSY1519103T00000X
CAPSY6649103T00000X
WA2413103TC0700X
VAPSY810001654103TC0700X
CAMFC6202106H00000X
WAPSY2413103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB28932Medicare ID - Type Unspecified