Provider Demographics
NPI:1396812525
Name:BETHEA, CHARLES WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BETHEA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:616-281-6459
Practice Address - Street 1:1050 SILVER DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5749
Practice Address - Country:US
Practice Address - Phone:231-947-2255
Practice Address - Fax:231-947-5982
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001279101YP2500X
MI68010104011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401001279OtherPROFESSIONAL COUNSELOR LI
MI6801010401OtherMASTER SOCIAL WORKER LICE
MI6801010401OtherMASTER SOCIAL WORKER LICE