MEDICARE: HEATHER L BEAUDRY PHD

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	103TC0700X	Clinical Psychologist	TN2735	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	042017	OTHER	PA	BLUE SHIELD

General Provider Information

NPI Number	:	1760464937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER L BEAUDRY PHD

Provider Business Mailing Address
First Line	:	1907 N ROAN ST STE 207
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-3182
Country	:	US
Telephone Number	:	423-282-0164
Fax Number	:

Provider Business Practice Location Address
First Line	:	1907 N ROAN ST STE 207
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-3182
Country	:	US
Telephone Number	:	423-282-0164
Fax Number	:

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	04/12/2021

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Directions to “ HEATHER L BEAUDRY PHD” Practice Location

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