Healthcare Provider Details

I. General information

NPI: 1336116680
Provider Name (Legal Business Name): CATHLEEN MARIE WALLEN BEAUSEIGNEUR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 SW SAINT LUCIE CRES SUITE 101
STUART FL
34994-2851
US

IV. Provider business mailing address

10864 SW BLUE MESA WAY
PORT SAINT LUCIE FL
34987-2138
US

V. Phone/Fax

Practice location:
  • Phone: 716-665-9805
  • Fax:
Mailing address:
  • Phone: 716-665-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8480
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR056450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: