Provider Demographics
NPI:1821227802
Name:BEAUREGARD, LISA MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 GARDENDALE CIR SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-2329
Mailing Address - Country:US
Mailing Address - Phone:321-258-2314
Mailing Address - Fax:
Practice Address - Street 1:245 CAHABA VALLEY PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-2217
Practice Address - Country:US
Practice Address - Phone:205-942-6820
Practice Address - Fax:205-942-5884
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist