Healthcare Provider Details

I. General information

NPI: 1154468825
Provider Name (Legal Business Name): THERESA MARIE BEAUREGARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50505 SCHOENHERR RD STE 120
SHELBY TOWNSHIP MI
48315-3140
US

IV. Provider business mailing address

5909 BELLE RIVER RD
CHINA MI
48054-3306
US

V. Phone/Fax

Practice location:
  • Phone: 586-710-2306
  • Fax: 586-412-4626
Mailing address:
  • Phone: 586-291-1335
  • Fax: 586-412-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000296
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: