Basic Information
| Provider Information | |||||||||
| NPI: | 1326452970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUVAIS-NIEZURAWSKI | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 89 W SOUTH BLVD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 89 W SOUTH BLVD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2014 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301016349 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 103TC1900X | 6301016349 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103T00000X | 6361001388 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.