MEDICARE: MRS. KATHLEEN KITTILA BEAULIEU ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1972655884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN KITTILA BEAULIEU ATC

Provider Business Mailing Address
First Line	:	116 ELMA DR
Second Line	:
City	:	NEWARK
State	:	DE
Zip	:	19711-8524
Country	:	US
Telephone Number	:	302-456-1791
Fax Number	:

Provider Business Practice Location Address
First Line	:	5114 N CHARLES ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21210-2021
Country	:	US
Telephone Number	:	410-649-3315
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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