Provider Demographics
NPI:1760811145
Name:BANAL, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BANAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 FORT DR NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-1870
Mailing Address - Country:US
Mailing Address - Phone:202-939-2010
Mailing Address - Fax:
Practice Address - Street 1:3815 FORT DR NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-1870
Practice Address - Country:US
Practice Address - Phone:202-939-2010
Practice Address - Fax:202-282-1116
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool