Provider Demographics
NPI:1518209568
Name:DETWILER, BETHANN WISE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:BETHANN
Middle Name:WISE
Last Name:DETWILER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5352 TWIN HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5682
Mailing Address - Country:US
Mailing Address - Phone:804-592-2793
Mailing Address - Fax:804-592-2794
Practice Address - Street 1:5352 TWIN HICKORY RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5682
Practice Address - Country:US
Practice Address - Phone:804-592-2793
Practice Address - Fax:804-592-2794
Is Sole Proprietor?:No
Enumeration Date:2013-03-17
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005427101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional