Provider Demographics
NPI:1710308804
Name:ERICSON, BETHANY (RD, LD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:ERICSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2639
Mailing Address - Country:US
Mailing Address - Phone:208-899-7933
Mailing Address - Fax:
Practice Address - Street 1:351 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2639
Practice Address - Country:US
Practice Address - Phone:208-899-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-778133V00000X
ORLDD10158487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered