Provider Demographics
NPI:1609352103
Name:MALLOY, BETHANY DEMASIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DEMASIE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:LYNN
Other - Last Name:DEMASIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4314
Mailing Address - Country:US
Mailing Address - Phone:336-375-2240
Mailing Address - Fax:
Practice Address - Street 1:2500 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4314
Practice Address - Country:US
Practice Address - Phone:336-375-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist