Provider Demographics
NPI:1952052532
Name:BETHEA, TAMALA TERRAL
Entity Type:Individual
Prefix:
First Name:TAMALA
Middle Name:TERRAL
Last Name:BETHEA
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 1:2024 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-2605
Mailing Address - Country:US
Mailing Address - Phone:484-597-2409
Mailing Address - Fax:
Practice Address - Street 1:525 E GAY ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-2718
Practice Address - Country:US
Practice Address - Phone:484-597-4091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA49143601171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA83-3838714Other2