Provider Demographics
NPI:1558146043
Name:ROUSSEL, BETHANEE RENEE'
Entity Type:Individual
Prefix:
First Name:BETHANEE
Middle Name:RENEE'
Last Name:ROUSSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANEE
Other - Middle Name:RENEE
Other - Last Name:ROUSSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5755 MARK DABLING BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2272
Mailing Address - Country:US
Mailing Address - Phone:719-966-1854
Mailing Address - Fax:
Practice Address - Street 1:5755 MARK DABLING BLVD STE 250
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2272
Practice Address - Country:US
Practice Address - Phone:719-966-1854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-279931106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician