Provider Demographics
NPI:1760652788
Name:IGO, BETHANY D'ANN (MED)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:D'ANN
Last Name:IGO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 SABER LN
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-2407
Mailing Address - Country:US
Mailing Address - Phone:405-255-0706
Mailing Address - Fax:
Practice Address - Street 1:2250 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-3351
Practice Address - Country:US
Practice Address - Phone:405-255-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK0000000000101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health