Provider Demographics
NPI:1356705222
Name:BETHEL FAMILY COUNSELING PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BETHEL FAMILY COUNSELING PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-933-9931
Mailing Address - Street 1:3737 CAMINO DEL RIO SOUTH
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4008
Mailing Address - Country:US
Mailing Address - Phone:619-933-9931
Mailing Address - Fax:619-516-3590
Practice Address - Street 1:3737 CAMINO DEL RIO S
Practice Address - Street 2:205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4006
Practice Address - Country:US
Practice Address - Phone:619-933-9931
Practice Address - Fax:619-516-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48619106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty