Provider Demographics
NPI:1609998061
Name:BEAUREGARD, MARK (RDT-BCT, LCAT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BEAUREGARD
Suffix:
Gender:M
Credentials:RDT-BCT, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BROADWAY STE 2130
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-3733
Mailing Address - Country:US
Mailing Address - Phone:917-204-2846
Mailing Address - Fax:
Practice Address - Street 1:225 BROADWAY STE 2130
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3733
Practice Address - Country:US
Practice Address - Phone:917-204-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000857221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist