Basic Information
| Provider Information | |||||||||
| NPI: | 1710133806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUREGARD | ||||||||
| FirstName: | AUDRA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 ELWOOD RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606439157 | ||||||||
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| Practice Location | |||||||||
| Address1: | 587 E MIDDLE TPKE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060403731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606463888 | ||||||||
| FaxNumber: | 8606454132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 004304 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.