Provider Demographics
NPI:1619219490
Name:BETHKE, DARLA K (CCC-SP)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:K
Last Name:BETHKE
Suffix:
Gender:F
Credentials:CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22706 ISLAMARE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-3634
Mailing Address - Country:US
Mailing Address - Phone:949-859-8158
Mailing Address - Fax:
Practice Address - Street 1:1301 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3808
Practice Address - Country:US
Practice Address - Phone:714-639-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP5328235Z00000X
CA956154473261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-6154473Medicare PIN