Provider Demographics
NPI:1538636790
Name:DIVITA, BETHANY BERNICE (MA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:BERNICE
Last Name:DIVITA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E FOURTH PLAIN BLVD.
Mailing Address - Street 2:BLDG. 17
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98861
Mailing Address - Country:US
Mailing Address - Phone:360-397-8246
Mailing Address - Fax:
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD.
Practice Address - Street 2:BLDG. 17
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health