Provider Demographics
NPI:1962092254
Name:BEAL, OCTAVIA
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:
Last Name:BEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42513 ASHLEY CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2301
Mailing Address - Country:US
Mailing Address - Phone:734-837-1889
Mailing Address - Fax:
Practice Address - Street 1:42513 ASHLEY CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2301
Practice Address - Country:US
Practice Address - Phone:734-837-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional