Provider Demographics
NPI:1013538123
Name:RACKERS, BETHANY RAE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:RAE
Last Name:RACKERS
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 1:1417 HIGHWAY P
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:MO
Mailing Address - Zip Code:65035-2407
Mailing Address - Country:US
Mailing Address - Phone:573-418-6766
Mailing Address - Fax:
Practice Address - Street 1:1417 HIGHWAY P
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:MO
Practice Address - Zip Code:65035-2407
Practice Address - Country:US
Practice Address - Phone:573-418-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-18-33156103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst