Provider Demographics
NPI:1790825859
Name:BEAUDRY, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BEAUDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1355
Practice Address - Country:US
Practice Address - Phone:617-548-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8472225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOT0170OtherBCBS PROVIDER ID