Provider Demographics
NPI:1710018296
Name:BETHEA, MARIE CATHERINE J A KELIN LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE CATHERINE J A
Middle Name:KELIN LEE
Last Name:BETHEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 WILTON MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4841
Mailing Address - Country:US
Mailing Address - Phone:919-773-1219
Mailing Address - Fax:
Practice Address - Street 1:3000 HIGHWOODS BLVD
Practice Address - Street 2:SUITE 128
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1027
Practice Address - Country:US
Practice Address - Phone:919-790-8533
Practice Address - Fax:919-790-8836
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0048411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003610Medicaid