Basic Information
| Provider Information | |||||||||
| NPI: | 1568717635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLINE | ||||||||
| OtherFirstName: | ELAINE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2627 E BELTLINE AVE SE STE 210 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162855100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2627 E BELTLINE AVE SE STE 210 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162855100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801057813 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.