Provider Demographics
NPI:1952468019
Name:BEAUFAIT, GARY R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:BEAUFAIT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1561
Mailing Address - Country:US
Mailing Address - Phone:856-256-8389
Mailing Address - Fax:
Practice Address - Street 1:1030 KINGS HWY N
Practice Address - Street 2:SUITE 210
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1907
Practice Address - Country:US
Practice Address - Phone:856-321-1900
Practice Address - Fax:856-321-1107
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00390700103G00000X
NJ35SI000390700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11575043OtherCAQH PROVIDER ID
NJ052251Medicare ID - Type UnspecifiedPROVIDER ID NUMBER
11575043OtherCAQH PROVIDER ID