Provider Demographics
NPI:1336827807
Name:KNOETTNER, BETHANY LYONS (MASTERS, CAGS)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYONS
Last Name:KNOETTNER
Suffix:
Gender:F
Credentials:MASTERS, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 KATE ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-3400
Mailing Address - Country:US
Mailing Address - Phone:617-620-9195
Mailing Address - Fax:
Practice Address - Street 1:2 KATE ROSE WAY
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3400
Practice Address - Country:US
Practice Address - Phone:617-620-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA360136103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool