Provider Demographics
NPI:1972264232
Name:BEASLEY, SHARONDA A (LAC)
Entity Type:Individual
Prefix:
First Name:SHARONDA
Middle Name:A
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1946
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-1946
Mailing Address - Country:US
Mailing Address - Phone:973-902-1012
Mailing Address - Fax:
Practice Address - Street 1:111 DUNNELL RD
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2678
Practice Address - Country:US
Practice Address - Phone:973-330-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00339300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health