Healthcare Provider Details

I. General information

NPI: 1609998061
Provider Name (Legal Business Name): MARK BEAUREGARD RDT-BCT, LCAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADWAY STE 2130
NEW YORK NY
10007-3733
US

IV. Provider business mailing address

225 BROADWAY STE 2130
NEW YORK NY
10007-3733
US

V. Phone/Fax

Practice location:
  • Phone: 917-204-2846
  • Fax:
Mailing address:
  • Phone: 917-204-2846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000857
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: