Provider Demographics
NPI:1770971129
Name:BEASLEY, ANTHANY JAYSEN (LMSW)
Entity type:Individual
Prefix:
First Name:ANTHANY
Middle Name:JAYSEN
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PEARL ST STE 304
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2663
Mailing Address - Country:US
Mailing Address - Phone:734-719-0448
Mailing Address - Fax:
Practice Address - Street 1:124 PEARL ST STE 304
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2663
Practice Address - Country:US
Practice Address - Phone:734-719-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2018-09-14
Deactivation Date:2018-08-23
Deactivation Code:
Reactivation Date:2018-08-29
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68010990661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801099066OtherSTATE LICENSE