Provider Demographics
NPI:1841717725
Name:BEACH, JOHN MADISON (LCSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MADISON
Last Name:BEACH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JOHNNY
Other - Middle Name:MADISON
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4443 LOUISIANA ST # SI
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4166
Mailing Address - Country:US
Mailing Address - Phone:503-516-0257
Mailing Address - Fax:
Practice Address - Street 1:7410 MISSION VALLEY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4405
Practice Address - Country:US
Practice Address - Phone:503-516-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR72351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical