Provider Demographics
NPI:1922417690
Name:NIELSEN, BETHANEY (DPT)
Entity Type:Individual
Prefix:
First Name:BETHANEY
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BETHANEY
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1208 VILLAGE CREEK LN APT 3
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6105
Mailing Address - Country:US
Mailing Address - Phone:931-237-6560
Mailing Address - Fax:
Practice Address - Street 1:1208 VILLAGE CREEK LN APT 3
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6105
Practice Address - Country:US
Practice Address - Phone:931-237-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC74322251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics