Provider Demographics
NPI:1093445587
Name:BETHUREM, AMANDA (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BETHUREM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 NW 79TH WAY
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-1155
Mailing Address - Country:US
Mailing Address - Phone:954-830-4123
Mailing Address - Fax:
Practice Address - Street 1:12811 KENWOOD LN STE 213
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5648
Practice Address - Country:US
Practice Address - Phone:239-539-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health