Provider Demographics
NPI:1184278921
Name:BEASLEY, NICOLE DIAUL
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DIAUL
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SEDRIC DR
Mailing Address - Street 2:
Mailing Address - City:DUSON
Mailing Address - State:LA
Mailing Address - Zip Code:70529-4414
Mailing Address - Country:US
Mailing Address - Phone:337-277-2372
Mailing Address - Fax:
Practice Address - Street 1:124 ABIGAYLE ROW
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-8909
Practice Address - Country:US
Practice Address - Phone:337-504-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty