Provider Demographics
NPI:1306172820
Name:BEASTER, CONNIE L (MS LPC)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:L
Last Name:BEASTER
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 FOREST GROVE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3894
Mailing Address - Country:US
Mailing Address - Phone:262-271-5511
Mailing Address - Fax:262-691-2972
Practice Address - Street 1:325 FOREST GROVE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3894
Practice Address - Country:US
Practice Address - Phone:262-271-5511
Practice Address - Fax:262-691-2972
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1976-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional