Provider Demographics
NPI:1750366175
Name:RICHERSON, BETHANY D (MPT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:D
Last Name:RICHERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NATCHEZ TRACE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7940
Mailing Address - Country:US
Mailing Address - Phone:270-796-4698
Mailing Address - Fax:270-782-3274
Practice Address - Street 1:165 NATCHEZ TRACE AVE
Practice Address - Street 2:STE 200
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7940
Practice Address - Country:US
Practice Address - Phone:270-796-4698
Practice Address - Fax:270-782-3274
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007579A225100000X
KY004243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000590928OtherBLUE CROSS BLUE SHIELD
IN000000280266OtherBLUE CROSS BLUE SHIELD
IN200839570Medicaid
IN200839570Medicaid
IN000000280266OtherBLUE CROSS BLUE SHIELD
IN206190Medicare ID - Type Unspecified
IN216070VMedicare PIN