MEDICARE: BEAKIE JORELISSE COLON RIVERA LCSWA, LCAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-23687	NC
2	1041C0700X	Clinical Social Worker	P011751	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P011715	OTHER	NC	NORTH CAROLINA LCSWA
2	LCAS-23687	OTHER	NC	NORTH CAROLINA LCAS

General Provider Information

NPI Number	:	1083135131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEAKIE JORELISSE COLON RIVERA LCSWA, LCAS

Provider Business Mailing Address
First Line	:	9317 58TH AVENUE CT SW APT Q302
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-6104
Country	:	US
Telephone Number	:	910-587-9432
Fax Number	:

Provider Business Practice Location Address
First Line	:	9317 58TH AVENUE CT SW APT Q302
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-6104
Country	:	US
Telephone Number	:	910-587-9432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	01/14/2020

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