Provider Demographics
NPI:1790286532
Name:WILSON, BETHANY RAY (APSS)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:
Credentials:APSS
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:RAY
Other - Last Name:RUCKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AS, CCHW, TCM, APSS
Mailing Address - Street 1:3677 BEATEN PATH
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8564
Mailing Address - Country:US
Mailing Address - Phone:859-209-1414
Mailing Address - Fax:
Practice Address - Street 1:333 WALLER AVE STE 250
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2915
Practice Address - Country:US
Practice Address - Phone:859-562-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1164221171M00000X
KY175T00000X
KYKCCHW12307238172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid