Provider Demographics
NPI:1205247319
Name:GENEVRO, BETHANY SUZANNE (MSCCCSLP)
Entity type:Individual
Prefix:MISS
First Name:BETHANY
Middle Name:SUZANNE
Last Name:GENEVRO
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MAIN STREET
Mailing Address - Street 2:PO BOX 10
Mailing Address - City:LAPORTE
Mailing Address - State:PA
Mailing Address - Zip Code:18626
Mailing Address - Country:US
Mailing Address - Phone:570-946-7700
Mailing Address - Fax:
Practice Address - Street 1:918 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626
Practice Address - Country:US
Practice Address - Phone:570-946-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL011871235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist