Healthcare Provider Details

I. General information

NPI: 1538277058
Provider Name (Legal Business Name): DENNIS MICHAEL BEAUFAIT ED D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E MARCY ST STE 202
SANTA FE NM
87501-2046
US

IV. Provider business mailing address

PO BOX 32390
SANTA FE NM
87594-2390
US

V. Phone/Fax

Practice location:
  • Phone: 888-982-3113
  • Fax:
Mailing address:
  • Phone: 888-982-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number005152
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2857
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4114
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: