Provider Demographics
NPI:1023627973
Name:LUCAS, BETHANY (RD, LD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:PENNOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2110 BUCKSKIN TRL
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2520 LONGVIEW ST STE 211
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-4201
Practice Address - Country:US
Practice Address - Phone:323-637-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered