Provider Demographics
NPI:1942887898
Name:CARLSON, BETHANY JEAN
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:JEAN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JEAN
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BETHANY ORTIZ
Mailing Address - Street 1:13865 REPOSA CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3268
Mailing Address - Country:US
Mailing Address - Phone:951-833-3233
Mailing Address - Fax:323-486-1440
Practice Address - Street 1:1000 SAN GABRIEL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4394
Practice Address - Country:US
Practice Address - Phone:232-498-2231
Practice Address - Fax:323-486-1440
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236417320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities