Provider Demographics
NPI:1093418931
Name:STANLEY, BETHANY E
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:E
Last Name:STANLEY
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 1:838 HEARD AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4206
Mailing Address - Country:US
Mailing Address - Phone:706-691-8645
Mailing Address - Fax:
Practice Address - Street 1:519 BLACKBURN DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-8202
Practice Address - Country:US
Practice Address - Phone:706-825-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional