Provider Demographics
NPI:1508497793
Name:MCCONNELL, BETHANNIE DAWN LYNETTE
Entity Type:Individual
Prefix:
First Name:BETHANNIE
Middle Name:DAWN LYNETTE
Last Name:MCCONNELL
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:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-1288
Mailing Address - Country:US
Mailing Address - Phone:985-707-2613
Mailing Address - Fax:
Practice Address - Street 1:1325 W CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3043
Practice Address - Country:US
Practice Address - Phone:855-345-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician