Provider Demographics
NPI:1891990321
Name:BEAULIEU, SUSANN
Entity Type:Individual
Prefix:
First Name:SUSANN
Middle Name:
Last Name:BEAULIEU
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 1:2112 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2330
Mailing Address - Country:US
Mailing Address - Phone:541-756-6337
Mailing Address - Fax:541-751-9908
Practice Address - Street 1:2112 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-2330
Practice Address - Country:US
Practice Address - Phone:541-756-6337
Practice Address - Fax:541-751-9908
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-1002441237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298922Medicaid