Healthcare Provider Details

I. General information

NPI: 1003908781
Provider Name (Legal Business Name): JOHN BEAUVAIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA CONNECTICUT HEALTHCARE SYSTEM (116B) 950 CAMPBELL AVENUE
WEST HAVEN CT
06516
US

IV. Provider business mailing address

136 BARBERRY ROAD
SOUTHPORT CT
06890
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax: 203-937-4951
Mailing address:
  • Phone: 203-254-0639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number002320
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002320
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: