Provider Demographics
NPI:1295961050
Name:BEASLEY, MARIE LEE (DO)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LEE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 TREMONT ST
Mailing Address - Street 2:SUITE 101, OFFICE A
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3038
Mailing Address - Country:US
Mailing Address - Phone:423-443-2120
Mailing Address - Fax:423-425-9923
Practice Address - Street 1:1222 TREMONT ST
Practice Address - Street 2:SUITE 101, OFFICE A
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3038
Practice Address - Country:US
Practice Address - Phone:423-443-2120
Practice Address - Fax:423-425-9923
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29372084P0804X, 2084P0804X
TNDO00000029372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295961050Medicaid