Provider Demographics
NPI:1700208188
Name:STREET, BETHANY (BS)
Entity Type:Individual
Prefix:MISS
First Name:BETHANY
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 SE QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:KS
Mailing Address - Zip Code:66725-2312
Mailing Address - Country:US
Mailing Address - Phone:620-875-9563
Mailing Address - Fax:
Practice Address - Street 1:111 S TREATY RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5327
Practice Address - Country:US
Practice Address - Phone:918-540-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst