Provider Demographics
NPI:1518035690
Name:JELENIC, BETHANY L (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:JELENIC
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W BIG BEAVER RD STE 125
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3915
Mailing Address - Country:US
Mailing Address - Phone:248-309-8900
Mailing Address - Fax:
Practice Address - Street 1:60 W BIG BEAVER RD STE 125
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3915
Practice Address - Country:US
Practice Address - Phone:248-309-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013215-1225X00000X
MI5201005298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
QT8281Medicare ID - Type Unspecified