Provider Demographics
NPI:1871186171
Name:NEAL, BETHANY ANN (LMT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANN
Last Name:NEAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2343
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2343
Mailing Address - Country:US
Mailing Address - Phone:931-636-4822
Mailing Address - Fax:
Practice Address - Street 1:1104 N 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3217
Practice Address - Country:US
Practice Address - Phone:208-292-4873
Practice Address - Fax:208-292-4875
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4336225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist