Provider Demographics
NPI:1871870485
Name:BEAUMONT, CONNIE A (SLP, IBCLC)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:A
Last Name:BEAUMONT
Suffix:
Gender:F
Credentials:SLP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8617 WHITE OAK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9477
Mailing Address - Country:US
Mailing Address - Phone:320-200-4473
Mailing Address - Fax:320-584-2660
Practice Address - Street 1:2848 2ND ST S STE 155
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3714
Practice Address - Country:US
Practice Address - Phone:320-200-4473
Practice Address - Fax:320-584-2660
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL-157708174N00000X
MN8718235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty