Provider Demographics
NPI:1053948216
Name:CARPENTER, BEULAH SUZANNE (LMT)
Entity type:Individual
Prefix:MRS
First Name:BEULAH
Middle Name:SUZANNE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1495 BRICK SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-5708
Mailing Address - Country:US
Mailing Address - Phone:262-607-0817
Mailing Address - Fax:
Practice Address - Street 1:700 GENEVA PKWY N
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4594
Practice Address - Country:US
Practice Address - Phone:262-249-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4607-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist