MEDICARE: BEAU MARTIN GRAY LPCC

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	101YP2500X	Professional Counselor	1778	MN

General Provider Information

NPI Number	:	1497181598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEAU MARTIN GRAY LPCC

Provider Business Mailing Address
First Line	:	2001 BEAM AVE
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-1401
Country	:	US
Telephone Number	:	952-737-4547
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 BEAM AVE
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109
Country	:	US
Telephone Number	:	952-737-4547
Fax Number	:

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

Provider Enumeration Date	:	09/20/2013
Last Update Date	:	06/12/2018

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