Healthcare Provider Details

I. General information

NPI: 1356078877
Provider Name (Legal Business Name): CAITLIN GRACE RAELEE BEAUCHAMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E SOUTHLAKE BLVD STE 150
SOUTHLAKE TX
76092-6276
US

IV. Provider business mailing address

251 E SOUTHLAKE BLVD STE 150
SOUTHLAKE TX
76092-6276
US

V. Phone/Fax

Practice location:
  • Phone: 817-424-0971
  • Fax:
Mailing address:
  • Phone: 817-424-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: