Provider Demographics
NPI:1457625444
Name:BEAULIEU, MICHELLE LEIGH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711A S GLENCOE RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8223
Mailing Address - Country:US
Mailing Address - Phone:386-566-2908
Mailing Address - Fax:386-738-3466
Practice Address - Street 1:711A S GLENCOE RD
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8223
Practice Address - Country:US
Practice Address - Phone:386-566-2908
Practice Address - Fax:386-738-3466
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0017384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist