Provider Demographics
NPI:1780030577
Name:BETHEA, LAKERA YANEE
Entity Type:Individual
Prefix:
First Name:LAKERA
Middle Name:YANEE
Last Name:BETHEA
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 1:2709 WILD POPLAR WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2709 WILD POPLAR WAY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-2970
Practice Address - Country:US
Practice Address - Phone:910-373-1219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222Q00000X, 251C00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No251C00000XAgenciesDay Training, Developmentally Disabled Services