=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326524208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEASLEY FAMILY THERAPY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2018
-----------------------------------------------------
Last Update Date | 07/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 PEARL ST STE 304
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-719-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1175 JAY AVE
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48198-6462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-719-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTHANY J BEASLEY
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 734-719-0448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------