Healthcare Provider Details

I. General information

NPI: 1205747094
Provider Name (Legal Business Name): MR. SAMUEL THAN BEADLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S ATWATER DR SUITE 130
MALVERN PA
19355
US

IV. Provider business mailing address

114 JUSTIN DR
WEST CHESTER PA
19382-3428
US

V. Phone/Fax

Practice location:
  • Phone: 610-646-1851
  • Fax:
Mailing address:
  • Phone: 860-416-5237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: