Provider Demographics
NPI:1164039905
Name:DILLON, BETHANY R (MA, LPCC, CCTP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:R
Last Name:DILLON
Suffix:
Gender:F
Credentials:MA, LPCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12918 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12918 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6001
Practice Address - Country:US
Practice Address - Phone:651-238-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01872101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health