Basic Information
Provider Information | |||||||||
NPI: | 1760428429 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEAULIEU | ||||||||
FirstName: | DENIS | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
Address2: | SUITE 306 | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 984991574 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535815200 | ||||||||
FaxNumber: | 2535815203 | ||||||||
Practice Location | |||||||||
Address1: | 17520 MERIDIAN E | ||||||||
Address2: | SUITE F | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 983756265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538647595 | ||||||||
FaxNumber: | 2538640457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2006 | ||||||||
LastUpdateDate: | 11/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00006407 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8415648 | 05 | WA |   | MEDICAID |