Provider Demographics
NPI:1639928153
Name:BEAULIEU, MICHELE ANN
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANN
Last Name:BEAULIEU
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 1:1718 BELGO RD APT 1
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:VT
Mailing Address - Zip Code:05735-5602
Mailing Address - Country:US
Mailing Address - Phone:207-831-5095
Mailing Address - Fax:
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4594
Practice Address - Country:US
Practice Address - Phone:802-775-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8064708103TB0200X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No172V00000XOther Service ProvidersCommunity Health Worker