Provider Demographics
NPI:1912365065
Name:BEAM, MARK (LMBT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BEAM
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BOSTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-6800
Mailing Address - Country:US
Mailing Address - Phone:980-521-6427
Mailing Address - Fax:
Practice Address - Street 1:6596 ROBERTA RD
Practice Address - Street 2:SUITE B
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-9400
Practice Address - Country:US
Practice Address - Phone:980-521-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13656225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist