Provider Demographics
NPI:1720697337
Name:BETHUNE, MELINDA (PTA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:BETHUNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130D SNOW BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8411
Mailing Address - Country:US
Mailing Address - Phone:336-904-0467
Mailing Address - Fax:336-497-3072
Practice Address - Street 1:1130D SNOW BRIDGE LN
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8411
Practice Address - Country:US
Practice Address - Phone:336-904-0467
Practice Address - Fax:336-497-3072
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7258225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant