Provider Demographics
NPI:1821203670
Name:BETHEL, LANNY RAY (PTA)
Entity Type:Individual
Prefix:MR
First Name:LANNY
Middle Name:RAY
Last Name:BETHEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MOUNT PELIA RD APT 16
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 HANNINGS LN
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3308
Practice Address - Country:US
Practice Address - Phone:731-587-3193
Practice Address - Fax:731-588-2732
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2032225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant