Basic Information
| Provider Information | |||||||||
| NPI: | 1053489658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAULIEU | ||||||||
| FirstName: | GEORGETTE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047691820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077647529 | ||||||||
| FaxNumber: | 2077646504 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047692660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077648573 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC1512 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5588 | 01 | ME | ANTHEM PROVIDER ID | OTHER |