Provider Demographics
NPI:1194803734
Name:BEACON CLINIC, INC.
Entity type:Organization
Organization Name:BEACON CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLDSWORTH
Authorized Official - Suffix:I
Authorized Official - Credentials:ARNP
Authorized Official - Phone:941-629-7855
Mailing Address - Street 1:3821 TAMIAMI TRL # D
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8377
Mailing Address - Country:US
Mailing Address - Phone:941-629-7855
Mailing Address - Fax:941-629-9589
Practice Address - Street 1:3821 TAMIAMI TRL # D
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8377
Practice Address - Country:US
Practice Address - Phone:941-629-7855
Practice Address - Fax:941-629-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNP2596452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1757Medicare ID - Type Unspecified