Provider Demographics
NPI:1790403202
Name:BETHANY, TERESA WILBURN (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:WILBURN
Last Name:BETHANY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SPLITROCK LN
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-5521
Mailing Address - Country:US
Mailing Address - Phone:210-392-5827
Mailing Address - Fax:
Practice Address - Street 1:109 SPLITROCK LN
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-5521
Practice Address - Country:US
Practice Address - Phone:210-392-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202850101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health