Provider Demographics
NPI:1396051637
Name:BETHONEY, JUSTIN NICHOLAS (NP)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:NICHOLAS
Last Name:BETHONEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SW SHEVLIN HIXON DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3232
Mailing Address - Country:US
Mailing Address - Phone:458-206-6251
Mailing Address - Fax:224-215-3993
Practice Address - Street 1:151 SW SHEVLIN HIXON DR STE 102
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3232
Practice Address - Country:US
Practice Address - Phone:458-206-6251
Practice Address - Fax:224-215-3993
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264824163WP0807X, 364SP0807X
CA95001312363LP0808X
OR201501392NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent