Provider Demographics
NPI:1962024232
Name:BETHEL, CAROLYN CORRINA
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:CORRINA
Last Name:BETHEL
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 1:2222 COLONIAL RD STE 1002222
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-5309
Mailing Address - Country:US
Mailing Address - Phone:772-489-4726
Mailing Address - Fax:
Practice Address - Street 1:2222 COLONIAL RD STE 1002222
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5309
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health