Provider Demographics
NPI:1134290091
Name:BETHUNE, DIANE H (ATR, LCAT, CASAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:BETHUNE
Suffix:
Gender:F
Credentials:ATR, LCAT, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAVERICK RD
Mailing Address - Street 2:APT 14
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1715
Mailing Address - Country:US
Mailing Address - Phone:845-679-5829
Mailing Address - Fax:
Practice Address - Street 1:239 GOLDEN HILL LN
Practice Address - Street 2:UCMHD
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6441
Practice Address - Country:US
Practice Address - Phone:845-340-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12659101YA0400X
NY000908221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist