Provider Demographics
NPI:1104237833
Name:BEASLEY, KRISTIN LEE
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LEE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 N WINERY AVE
Mailing Address - Street 2:#101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-4817
Mailing Address - Country:US
Mailing Address - Phone:559-252-6353
Mailing Address - Fax:
Practice Address - Street 1:2080 N WINERY AVE
Practice Address - Street 2:#101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-4817
Practice Address - Country:US
Practice Address - Phone:559-252-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94020449103TC0700X, 103TC1900X, 103TA0400X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily