Provider Demographics
NPI:1619113420
Name:WILLIS, BETHANY D'AUN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:D'AUN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 UNSER BLVD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4045
Mailing Address - Country:US
Mailing Address - Phone:505-896-0928
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4045
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0795106H00000X
WALF60309365106H00000X
NMCMF0218751106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2091942Medicaid