Provider Demographics
NPI:1275266983
Name:COOGAN, BETHANY GRACE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:GRACE
Last Name:COOGAN
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 1:2323 W CHESTNUT ST STE 6
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3520
Mailing Address - Country:US
Mailing Address - Phone:479-346-5459
Mailing Address - Fax:
Practice Address - Street 1:2323 W CHESTNUT ST STE 6
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3520
Practice Address - Country:US
Practice Address - Phone:479-346-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-23-29666106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician