Provider Demographics
NPI:1083500284
Name:BURROUGHS, BETHANY RENEE
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:RENEE
Last Name:BURROUGHS
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 1:780 LYNNHAVEN PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7332
Mailing Address - Country:US
Mailing Address - Phone:301-752-3211
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 250
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:034-922-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA25-443280106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician