Provider Demographics
NPI:1376214460
Name:BETHEL, MARISA RENEE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:RENEE
Last Name:BETHEL
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 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6274
Mailing Address - Country:US
Mailing Address - Phone:309-347-5522
Mailing Address - Fax:
Practice Address - Street 1:111 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2532
Practice Address - Country:US
Practice Address - Phone:309-694-6462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
101YA0400XOtherTAXONOMY