Provider Demographics
NPI:1700654027
Name:OVERSTREET, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:OVERSTREET
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 1:111 WATER MARQ PATH APT 1042
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8316
Mailing Address - Country:US
Mailing Address - Phone:270-775-3994
Mailing Address - Fax:
Practice Address - Street 1:1716 SHARKEY WAY STE 200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2096
Practice Address - Country:US
Practice Address - Phone:270-775-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245906225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist