Provider Demographics
NPI:1366206476
Name:BEAULIEU, CLAYTON
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:BEAULIEU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 CORNWALL AVE
Mailing Address - Street 2:STE. 205
Mailing Address - City:BELLINGHAM AVE
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:360-671-3574
Practice Address - Street 1:1616 CORNWALL AVE STE 205
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4642
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-671-3574
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WA1366206476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker