Healthcare Provider Details

I. General information

NPI: 1053809004
Provider Name (Legal Business Name): BEAU PALMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MULBERRY ST
LANCASTER OH
43130-3014
US

IV. Provider business mailing address

110 HIGHLAND AVE
CIRCLEVILLE OH
43113-1208
US

V. Phone/Fax

Practice location:
  • Phone: 740-277-7512
  • Fax:
Mailing address:
  • Phone: 740-477-2779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.163863
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: