Provider Demographics
NPI:1952635005
Name:WHITEHEAD, BETHANY (CCM)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 N UNIVERSITY AVE
Mailing Address - Street 2:APT. # 15
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1161 E 300 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3539
Practice Address - Country:US
Practice Address - Phone:801-373-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator