Provider Demographics
NPI:1134217508
Name:BEAUREGARD-WEISS, MARIE C (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:C
Last Name:BEAUREGARD-WEISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 WOODLAND WATERS BLVD
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6410
Mailing Address - Country:US
Mailing Address - Phone:917-470-0284
Mailing Address - Fax:352-293-3137
Practice Address - Street 1:2078 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3916
Practice Address - Country:US
Practice Address - Phone:917-470-0284
Practice Address - Fax:352-293-3137
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0507941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02455636Medicaid
N402T1Medicare ID - Type Unspecified