MEDICARE: STEPHANIE A BEAULIEU BCBA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1386814937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE A BEAULIEU BCBA

Provider Business Mailing Address
First Line	:	4630 N GREENVIEW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4626
Country	:	US
Telephone Number	:	913-485-8151
Fax Number	:

Provider Business Practice Location Address
First Line	:	4630 N GREENVIEW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4626
Country	:	US
Telephone Number	:	913-485-8151
Fax Number	:

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

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	01/10/2012

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