Provider Demographics
NPI:1104181353
Name:STEPHENSON, BETHANY D
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:D
Last Name:STEPHENSON
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:PO BOX 118008
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-8008
Mailing Address - Country:US
Mailing Address - Phone:843-302-8845
Mailing Address - Fax:843-569-5872
Practice Address - Street 1:9263 MEDICAL PLAZA DR
Practice Address - Street 2:STE D
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7109
Practice Address - Country:US
Practice Address - Phone:843-302-8845
Practice Address - Fax:832-569-5872
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist