Provider Demographics
NPI:1578697876
Name:D'ANTONIO, BETHANY SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:SUZANNE
Last Name:D'ANTONIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 WHETSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:MD
Mailing Address - Zip Code:21830-1149
Mailing Address - Country:US
Mailing Address - Phone:410-860-5871
Mailing Address - Fax:
Practice Address - Street 1:9715 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3500
Practice Address - Country:US
Practice Address - Phone:410-641-4400
Practice Address - Fax:410-641-0011
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17652314000000X
DEJ1000974314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD17652OtherLICENSE NUMBER
DEJ1000974OtherLICENSE NUMBER