Provider Demographics
NPI:1912006511
Name:WALLS, BETHANY J (OCCUPATIONAL THERAPI)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:J
Last Name:WALLS
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 396
Mailing Address - Street 2:
Mailing Address - City:ALBRIGHT
Mailing Address - State:WV
Mailing Address - Zip Code:26519-9768
Mailing Address - Country:US
Mailing Address - Phone:304-379-6577
Mailing Address - Fax:
Practice Address - Street 1:6500 THAYER CTR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1116
Practice Address - Country:US
Practice Address - Phone:301-334-1863
Practice Address - Fax:301-334-5835
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05259225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH0009OtherFEDERAL BCBS
MD61968501OtherCAREFIRST BCBS
MD6157478OtherCIGNA
WV7502154000Medicaid