Healthcare Provider Details

I. General information

NPI: 1588671432
Provider Name (Legal Business Name): PAT M BEAUPRE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 BROOKSIDE AVE
REDLANDS CA
92373-4611
US

IV. Provider business mailing address

PO BOX 293
BRYN MAWR CA
92318-0293
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-6005
  • Fax: 909-335-8514
Mailing address:
  • Phone: 909-335-6005
  • Fax: 909-335-8514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 14953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: