Provider Demographics
NPI:1417531997
Name:GREEN, BETHANY R (MSW)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 MISSISSIPPI AVE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1378
Mailing Address - Country:US
Mailing Address - Phone:863-838-5097
Mailing Address - Fax:
Practice Address - Street 1:1016 MISSISSIPPI AVE UNIT 102
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1378
Practice Address - Country:US
Practice Address - Phone:863-838-5097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical