Basic Information
| Provider Information | |||||||||
| NPI: | 1306368444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEBEAUCOURT | ||||||||
| FirstName: | BONNY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CASE MANAGER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOUTIN | ||||||||
| OtherFirstName: | BONNY | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CASE MANAGER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 CRIMSON CT | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014534756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085212287 | ||||||||
| FaxNumber: | 5085805162 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 ERDMAN WAY # 208 | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014531840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788701840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 07/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.