Provider Demographics
NPI:1841391877
Name:LIST, BETH ANNE (LLP LPC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANNE
Last Name:LIST
Suffix:
Gender:F
Credentials:LLP LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15209 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9570
Mailing Address - Country:US
Mailing Address - Phone:269-781-9119
Mailing Address - Fax:269-789-4347
Practice Address - Street 1:15209 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9570
Practice Address - Country:US
Practice Address - Phone:269-781-9119
Practice Address - Fax:269-789-4347
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003307101YP2500X
MI6301006717103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509107630OtherBCBS OF MI