Provider Demographics
NPI:1104380864
Name:DOWLING, BETHANY DIANE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DIANE
Last Name:DOWLING
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 1:25522 STATE HIGHWAY 75
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-3365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 FLOYD BRADFORD RD
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-3141
Practice Address - Country:US
Practice Address - Phone:205-305-8705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty