Provider Demographics
NPI:1699011346
Name:BETHEL, NANCY J (SLP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:BETHEL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LEWIS AVE S
Mailing Address - Street 2:STE#210
Mailing Address - City:WATERTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55388-4545
Mailing Address - Country:US
Mailing Address - Phone:952-955-2242
Mailing Address - Fax:952-955-2010
Practice Address - Street 1:4444 RESERVOIR BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-3255
Practice Address - Country:US
Practice Address - Phone:952-955-2242
Practice Address - Fax:952-955-2010
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5687235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist