Provider Demographics
NPI:1699117853
Name:BEAUDOIN, ERIC TYLER (PSYD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:TYLER
Last Name:BEAUDOIN
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 1:20 WEST ST APT 8
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3442
Mailing Address - Country:US
Mailing Address - Phone:207-441-8533
Mailing Address - Fax:
Practice Address - Street 1:20 FAIRFIELD HILL RD
Practice Address - Street 2:
Practice Address - City:KENNEBUNKPORT
Practice Address - State:ME
Practice Address - Zip Code:04046-5222
Practice Address - Country:US
Practice Address - Phone:207-441-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2022-03-18
Deactivation Date:2022-02-17
Deactivation Code:
Reactivation Date:2022-03-01
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101YM0800X
MEPS1532103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health