Basic Information
| Provider Information | |||||||||
| NPI: | 1700068558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | TY | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2619 N HARVEY AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731033017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055253959 | ||||||||
| FaxNumber: | 4055253439 | ||||||||
| Practice Location | |||||||||
| Address1: | 2619 N HARVEY AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731033017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055253959 | ||||||||
| FaxNumber: | 4055253439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.