Provider Demographics
NPI:1841803236
Name:BEASLEY, DEREK (CDCA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 LYNHURST AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2712
Mailing Address - Country:US
Mailing Address - Phone:937-422-2902
Mailing Address - Fax:
Practice Address - Street 1:4124 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3018
Practice Address - Country:US
Practice Address - Phone:937-422-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170758101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty