Healthcare Provider Details

I. General information

NPI: 1326633116
Provider Name (Legal Business Name): DUSTIN BEATY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 VISTA PARK DR STE A
FOREST VA
24551-4362
US

IV. Provider business mailing address

1047 VISTA PARK DR STE A
FOREST VA
24551-4362
US

V. Phone/Fax

Practice location:
  • Phone: 434-616-2388
  • Fax:
Mailing address:
  • Phone: 434-616-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704013722
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: