Provider Demographics
NPI:1912045832
Name:BEAUDRY, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BEAUDRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 ESCANYO DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4134
Mailing Address - Country:US
Mailing Address - Phone:650-583-9120
Mailing Address - Fax:
Practice Address - Street 1:1720 S AMPHLETT BLVD
Practice Address - Street 2:SUITE 123
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2702
Practice Address - Country:US
Practice Address - Phone:650-578-8691
Practice Address - Fax:650-578-8697
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor