Provider Demographics
NPI:1740513985
Name:BETHANY-FULCHER, DEDRA F (LCSW)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:F
Last Name:BETHANY-FULCHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DEDRA
Other - Middle Name:F
Other - Last Name:BETHANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN/LCSW
Mailing Address - Street 1:439 W 97TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3968
Mailing Address - Country:US
Mailing Address - Phone:323-754-2856
Mailing Address - Fax:323-754-1843
Practice Address - Street 1:439 W 97TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3968
Practice Address - Country:US
Practice Address - Phone:323-754-2856
Practice Address - Fax:323-754-1843
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical