Provider Demographics
NPI:1518633379
Name:BALENTINE, BETHANY (RD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BALENTINE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W DIAMOND AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1469
Mailing Address - Country:US
Mailing Address - Phone:301-315-3826
Mailing Address - Fax:
Practice Address - Street 1:200 E VINE ST STE B
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5531
Practice Address - Country:US
Practice Address - Phone:443-358-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5406133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered