Provider Demographics
NPI:1669909644
Name:ZICH, BETHANY LYNN (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:ZICH
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W WHITE ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4804
Mailing Address - Country:US
Mailing Address - Phone:217-366-1270
Mailing Address - Fax:
Practice Address - Street 1:2110 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7553
Practice Address - Country:US
Practice Address - Phone:217-366-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist