Provider Demographics
NPI:1720388374
Name:MINK, BETHANY ROSE (LMFT, PSYD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:MINK
Suffix:
Gender:F
Credentials:LMFT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5504
Mailing Address - Country:US
Mailing Address - Phone:248-830-0303
Mailing Address - Fax:
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-606-0296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79616106H00000X
CA30519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist