Provider Demographics
NPI:1881010494
Name:MIX, BETH (MA)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:
Last Name:MIX
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:6488 PORTAGE PATH CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9584
Mailing Address - Country:US
Mailing Address - Phone:614-539-1104
Mailing Address - Fax:
Practice Address - Street 1:2525 HOLTON RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-8985
Practice Address - Country:US
Practice Address - Phone:614-801-8025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 4020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist