Provider Demographics
NPI:1578779039
Name:BETHEL, LARRY ROGER (MS)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ROGER
Last Name:BETHEL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 BROADWAY ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2503
Mailing Address - Country:US
Mailing Address - Phone:913-461-6879
Mailing Address - Fax:
Practice Address - Street 1:3619 BROADWAY ST
Practice Address - Street 2:SUITE 12
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2503
Practice Address - Country:US
Practice Address - Phone:913-461-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist