Provider Demographics
NPI:1417547639
Name:GHATTAS, BETHANY ROSE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:GHATTAS
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 1:1149 FAIRCHILD AVE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-1811
Mailing Address - Country:US
Mailing Address - Phone:440-384-4068
Mailing Address - Fax:
Practice Address - Street 1:960 GRAHAM RD STE 3
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1155
Practice Address - Country:US
Practice Address - Phone:330-422-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OHC.2103737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)