Provider Demographics
NPI:1619719127
Name:SANFORD, BETHANY (LLPC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 WILSON AVE SW STE 252
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1206
Mailing Address - Country:US
Mailing Address - Phone:616-320-1528
Mailing Address - Fax:
Practice Address - Street 1:2905 WILSON AVE SW STE 252
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1206
Practice Address - Country:US
Practice Address - Phone:616-320-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023027101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health