Healthcare Provider Details

I. General information

NPI: 1356849509
Provider Name (Legal Business Name): MR. STEPHEN BEAUSOLEIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 HORSESHOE DR S STE 404
NAPLES FL
34104-6155
US

IV. Provider business mailing address

17071 CAROLYN LN
NORTH FORT MYERS FL
33917-3866
US

V. Phone/Fax

Practice location:
  • Phone: 800-217-9289
  • Fax: 888-751-4019
Mailing address:
  • Phone: 239-849-6290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: