Provider Demographics
NPI:1184976284
Name:BEACH, CHARLIE ANNE
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:ANNE
Last Name:BEACH
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 1:2725 HIGHWAY 550 NW
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-8537
Mailing Address - Country:US
Mailing Address - Phone:601-754-3331
Mailing Address - Fax:
Practice Address - Street 1:4109 HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-9132
Practice Address - Country:US
Practice Address - Phone:601-276-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2258225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2925Medicaid