Provider Demographics
NPI:1558843227
Name:WADE, BETHANY LAUREN
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LAUREN
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 REDBIRD CIR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37724-4178
Mailing Address - Country:US
Mailing Address - Phone:865-279-1989
Mailing Address - Fax:
Practice Address - Street 1:19TH ST
Practice Address - Street 2:809
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:866-755-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator