Provider Demographics
NPI:1356722086
Name:HANSEN, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:ANN
Other - Last Name:JORDAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1920 BRIARCLIFF RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4010
Mailing Address - Country:US
Mailing Address - Phone:404-785-9498
Mailing Address - Fax:
Practice Address - Street 1:1920 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4010
Practice Address - Country:US
Practice Address - Phone:404-785-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist