Provider Demographics
NPI:1477195543
Name:SMITH, BETHANY GRACE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:GRACE
Last Name:SMITH
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 1:260 S. MARION AVENUE
Mailing Address - Street 2:BUILDING A, SUITE 135
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025
Mailing Address - Country:US
Mailing Address - Phone:352-373-4411
Mailing Address - Fax:352-373-4455
Practice Address - Street 1:260 S. MARION AVENUE
Practice Address - Street 2:BUILDING A, SUITE 135
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:352-373-4411
Practice Address - Fax:352-373-4455
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist