Provider Demographics
NPI:1689097925
Name:HOLDER, BETHANY (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HALF MOON TRL
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0215
Mailing Address - Country:US
Mailing Address - Phone:949-842-7884
Mailing Address - Fax:949-364-6334
Practice Address - Street 1:616 S EL CAMINO REAL
Practice Address - Street 2:SUITE G-9
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4298
Practice Address - Country:US
Practice Address - Phone:949-427-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52156106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist