Provider Demographics
NPI:1780320804
Name:LANIS, BETHANY (MA LADC LPCC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LANIS
Suffix:
Gender:F
Credentials:MA LADC LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7759 142ND ST W
Mailing Address - Street 2:APT 108
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124
Mailing Address - Country:US
Mailing Address - Phone:715-441-6789
Mailing Address - Fax:
Practice Address - Street 1:7759 142ND ST W
Practice Address - Street 2:APT 108
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:715-441-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305608101YA0400X
MN3320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)