Provider Demographics
NPI:1831605310
Name:TAYLOR, BETHANY DIEDRICH (LICSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:DIEDRICH
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:KRISTEN
Other - Last Name:DIEDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:99 WATER ST UNIT 204
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-3084
Mailing Address - Country:US
Mailing Address - Phone:401-556-9044
Mailing Address - Fax:
Practice Address - Street 1:99 WATER ST UNIT 204
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-3084
Practice Address - Country:US
Practice Address - Phone:401-556-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW032841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIISW03284OtherASSOCIATION OF SOCIAL WORK BOARD