Provider Demographics
NPI:1578073771
Name:CHANDLER, BETHANY ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MYERS LN
Mailing Address - Street 2:
Mailing Address - City:SCHUYLERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12871-1161
Mailing Address - Country:US
Mailing Address - Phone:518-796-2361
Mailing Address - Fax:
Practice Address - Street 1:80 EAST LABARGE STREET
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839
Practice Address - Country:US
Practice Address - Phone:518-747-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1019941041C0700X
NY14227052011041S0200X
NY0900471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101994Medicaid