Provider Demographics
NPI:1336539113
Name:BEAM, HEATHER (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:BEAM
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 N HOLLAND SYLVANIA RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1823
Mailing Address - Country:US
Mailing Address - Phone:419-346-8269
Mailing Address - Fax:
Practice Address - Street 1:2722 N HOLLAND SYLVANIA RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-1823
Practice Address - Country:US
Practice Address - Phone:419-346-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-07-3743103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091093Medicaid