Provider Demographics
NPI:1821649898
Name:BEATTY, STEPHAN (LPC, ICT)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:BEATTY
Suffix:
Gender:M
Credentials:LPC, ICT
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC,ICT
Mailing Address - Street 1:1605 ROCK PRAIRIE RD STE 316
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8358
Mailing Address - Country:US
Mailing Address - Phone:979-291-2278
Mailing Address - Fax:
Practice Address - Street 1:1605 ROCK PRAIRIE RD STE 316
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:979-291-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74207101YM0800X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor