Provider Demographics
NPI:1396879078
Name:BEAUDELAIRE, JOHN (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BEAUDELAIRE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2701
Mailing Address - Country:US
Mailing Address - Phone:307-674-4405
Mailing Address - Fax:
Practice Address - Street 1:1221 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2701
Practice Address - Country:US
Practice Address - Phone:307-674-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT186101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health