Provider Demographics
NPI:1811362445
Name:BACON, BETH (OTR)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-2817
Mailing Address - Country:US
Mailing Address - Phone:512-968-2112
Mailing Address - Fax:
Practice Address - Street 1:5205 KINGS HWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2817
Practice Address - Country:US
Practice Address - Phone:512-968-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115626225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist