Provider Demographics
NPI:1346973906
Name:DUTRO, BETHANY ANN (CDCA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANN
Last Name:DUTRO
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1131
Practice Address - Country:US
Practice Address - Phone:440-328-4213
Practice Address - Fax:440-328-4214
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.181150101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)