Provider Demographics
NPI:1801990072
Name:CONKLIN, BETHANY L (LMP)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:L
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 SAND HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9451
Mailing Address - Country:US
Mailing Address - Phone:509-882-2472
Mailing Address - Fax:
Practice Address - Street 1:211 EUCLID ROAD
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1160
Practice Address - Country:US
Practice Address - Phone:509-882-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist