Provider Demographics
NPI:1790286532
Name:WILSON, BETHANY RAY (APSS)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:APSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 ELM TREE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-2117
Mailing Address - Country:US
Mailing Address - Phone:859-218-6165
Mailing Address - Fax:
Practice Address - Street 1:217 ELM TREE LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-2117
Practice Address - Country:US
Practice Address - Phone:859-218-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid