Provider Demographics
NPI:1861972754
Name:BEATTY-OLIVER, TRUDY (BS, LBSW, CMHP, QMHP)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:BEATTY-OLIVER
Suffix:
Gender:F
Credentials:BS, LBSW, CMHP, QMHP
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 148
Mailing Address - Street 2:
Mailing Address - City:MIO
Mailing Address - State:MI
Mailing Address - Zip Code:48647-0148
Mailing Address - Country:US
Mailing Address - Phone:989-826-3208
Mailing Address - Fax:989-826-6779
Practice Address - Street 1:42 N MOUNT TOM RD
Practice Address - Street 2:
Practice Address - City:MIO
Practice Address - State:MI
Practice Address - Zip Code:48647-8739
Practice Address - Country:US
Practice Address - Phone:989-826-3208
Practice Address - Fax:989-826-6779
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802081237104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker