Provider Demographics
NPI:1902411069
Name:BETHEL, TIMEICA E
Entity Type:Individual
Prefix:MRS
First Name:TIMEICA
Middle Name:E
Last Name:BETHEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 W POLK ST STE 100-240
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 W POLK ST STE 100-240
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2000
Practice Address - Country:US
Practice Address - Phone:872-903-0461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator