Provider Demographics
NPI:1104363126
Name:GREEN, BETHANY THERESA (LMT)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:THERESA
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7690 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9536
Mailing Address - Country:US
Mailing Address - Phone:352-246-1008
Mailing Address - Fax:352-505-3631
Practice Address - Street 1:1002 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5403
Practice Address - Country:US
Practice Address - Phone:352-494-5552
Practice Address - Fax:352-505-3631
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-28
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA83311225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist