MEDICARE: MRS. KELLY SUE BEAUDOIN MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT10464	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073627576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY SUE BEAUDOIN MPT

Provider Business Mailing Address
First Line	:	23175 COMMERCE PARK
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5806
Country	:	US
Telephone Number	:	440-449-3400
Fax Number	:	440-449-3402

Provider Business Practice Location Address
First Line	:	23175 COMMERCE PARK
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5806
Country	:	US
Telephone Number	:	440-449-3400
Fax Number	:	440-449-3402

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	03/27/2019

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