Provider Demographics
NPI:1598373169
Name:TECSON, BETHANY MICHAELA-CLARK (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:MICHAELA-CLARK
Last Name:TECSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:MICHAELA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:260 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1104
Mailing Address - Country:US
Mailing Address - Phone:586-431-2384
Mailing Address - Fax:
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1431
Practice Address - Country:US
Practice Address - Phone:810-412-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010901225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134125131Medicaid