Provider Demographics
NPI:1649759309
Name:BETHLEY, NADIA NICOLE (PHD)
Entity Type:Individual
Prefix:MS
First Name:NADIA
Middle Name:NICOLE
Last Name:BETHLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:662-741-2700
Practice Address - Street 1:2363 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-8337
Practice Address - Country:US
Practice Address - Phone:662-334-1253
Practice Address - Fax:662-741-2700
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS59-1030103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical