Provider Demographics
NPI:1417736661
Name:BETHEL, STEPHANIE ANN (LSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:BETHEL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1980
Mailing Address - Country:US
Mailing Address - Phone:618-985-4344
Mailing Address - Fax:
Practice Address - Street 1:310 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1980
Practice Address - Country:US
Practice Address - Phone:618-985-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111192101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health