Provider Demographics
NPI:1538277058
Name:BEAUFAIT, DENNIS MICHAEL (ED D)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MICHAEL
Last Name:BEAUFAIT
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32390
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87594-2390
Mailing Address - Country:US
Mailing Address - Phone:888-982-3113
Mailing Address - Fax:
Practice Address - Street 1:119 E MARCY ST STE 202
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2046
Practice Address - Country:US
Practice Address - Phone:888-982-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI005152103T00000X
CO2857103TC0700X
AZ4114103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON61880Medicare ID - Type Unspecified
MINZ0450005Medicare ID - Type Unspecified