Provider Demographics
NPI:1992364517
Name:FENKER, BETHANY (ST)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:FENKER
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1907
Mailing Address - Country:US
Mailing Address - Phone:317-584-5166
Mailing Address - Fax:317-815-3861
Practice Address - Street 1:3948 NEW VISION DR STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1721
Practice Address - Country:US
Practice Address - Phone:260-245-1455
Practice Address - Fax:317-815-3861
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007200A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist