Provider Demographics
NPI:1023668258
Name:FANCHER, BETHANY JEAN (LMT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:JEAN
Last Name:FANCHER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 30TH ST APT B45
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-3008
Mailing Address - Country:US
Mailing Address - Phone:718-755-5361
Mailing Address - Fax:
Practice Address - Street 1:3408 30TH ST APT B45
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-3008
Practice Address - Country:US
Practice Address - Phone:718-755-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11756225700000X
NY009725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist