Provider Demographics
NPI:1770900698
Name:WIGINTON, BETHANY MARIE (BA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:MARIE
Last Name:WIGINTON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S. PEORIA,
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-1399
Practice Address - Street 1:2325 S. HARVARD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3300
Practice Address - Country:US
Practice Address - Phone:918-712-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor