Provider Demographics
NPI:1205162443
Name:BEILBY, MICHELLE
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:BEILBY
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 1:7314 STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-3049
Mailing Address - Country:US
Mailing Address - Phone:763-220-0433
Mailing Address - Fax:
Practice Address - Street 1:7314 STAGECOACH TRL
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-3049
Practice Address - Country:US
Practice Address - Phone:763-220-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800791390200000X
MN2412106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN305472100Medicaid
MNC04024Medicare PIN