Provider Demographics
NPI:1417654781
Name:HARRIS, BETHANY LUANNE (PHD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LUANNE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28210 PASEO DR STE 190
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5377
Mailing Address - Country:US
Mailing Address - Phone:813-430-2101
Mailing Address - Fax:
Practice Address - Street 1:28210 PASEO DR STE 190
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5377
Practice Address - Country:US
Practice Address - Phone:813-430-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12002103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical