Provider Demographics
NPI:1306668256
Name:BEASLEY, OPHELIA
Entity type:Individual
Prefix:
First Name:OPHELIA
Middle Name:
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 1:2115 HART AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-2836
Mailing Address - Country:US
Mailing Address - Phone:912-220-3565
Mailing Address - Fax:
Practice Address - Street 1:2115 HART AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-2836
Practice Address - Country:US
Practice Address - Phone:912-220-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional