Provider Demographics
NPI:1740972652
Name:SELF, BETHANY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:MALM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSCCC-SLP
Mailing Address - Street 1:309 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-9069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 E FOX FARM RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2556
Practice Address - Country:US
Practice Address - Phone:307-763-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-1270235Z00000X
COSLP.0005100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist