Provider Demographics
NPI:1104491190
Name:BEAUSOLEIL, JOSHUA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BEAUSOLEIL
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6366
Mailing Address - Country:US
Mailing Address - Phone:313-520-0080
Mailing Address - Fax:
Practice Address - Street 1:790 LETICA DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1581
Practice Address - Country:US
Practice Address - Phone:248-841-8754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist