Provider Demographics
NPI:1326377367
Name:VASSANTACHART, BETHANEE VERIANNA (DPT)
Entity Type:Individual
Prefix:
First Name:BETHANEE
Middle Name:VERIANNA
Last Name:VASSANTACHART
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1189 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8123
Mailing Address - Country:US
Mailing Address - Phone:909-307-9121
Mailing Address - Fax:909-307-9161
Practice Address - Street 1:1189 W STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8123
Practice Address - Country:US
Practice Address - Phone:909-307-9121
Practice Address - Fax:909-307-9161
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEN495ZMedicare UPIN