Provider Demographics
NPI:1740581917
Name:PUTZ, BETHANY DAWN
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DAWN
Last Name:PUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:DAWN
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:
Practice Address - Street 1:2201 MACARTHUR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3161
Practice Address - Country:US
Practice Address - Phone:402-926-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9228101YM0800X
TX71356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health