Provider Demographics
NPI:1174612329
Name:BETHEA, ROSA HAYWOOD (BA)
Entity type:Individual
Prefix:MRS
First Name:ROSA
Middle Name:HAYWOOD
Last Name:BETHEA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5311 HUB JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7821
Mailing Address - Country:US
Mailing Address - Phone:910-222-6375
Mailing Address - Fax:910-678-9963
Practice Address - Street 1:711 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5193
Practice Address - Country:US
Practice Address - Phone:910-222-6375
Practice Address - Fax:910-678-9963
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children