Healthcare Provider Details

I. General information

NPI: 1235534512
Provider Name (Legal Business Name): BEAU S DANTIN LMFT, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 WEYMOUTH DR
BATON ROUGE LA
70809-1481
US

IV. Provider business mailing address

2325 WEYMOUTH DR
BATON ROUGE LA
70809-1481
US

V. Phone/Fax

Practice location:
  • Phone: 225-361-0899
  • Fax: 337-855-1829
Mailing address:
  • Phone: 225-361-0899
  • Fax: 337-855-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4770
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number4770
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number4770
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4770
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: