Healthcare Provider Details

I. General information

NPI: 1750295036
Provider Name (Legal Business Name): MICHELLE BEAUDREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19619 MOUNTAINEER WAY
BEND OR
97702-6500
US

IV. Provider business mailing address

520 NW WALL ST
BEND OR
97703-2608
US

V. Phone/Fax

Practice location:
  • Phone: 541-355-1060
  • Fax:
Mailing address:
  • Phone: 541-355-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101529
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: