Provider Demographics
NPI:1386730992
Name:BEAZER, RUSSELL GLEN (MS)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:GLEN
Last Name:BEAZER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 E BOSTON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6241
Mailing Address - Country:US
Mailing Address - Phone:480-649-6499
Mailing Address - Fax:480-207-2580
Practice Address - Street 1:1760 E BOSTON ST STE 102
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6241
Practice Address - Country:US
Practice Address - Phone:480-649-6499
Practice Address - Fax:480-207-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-10047106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist