Provider Demographics
NPI:1841877966
Name:BETHEL, KAYLA M
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:BETHEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 DEVENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1910
Mailing Address - Country:US
Mailing Address - Phone:909-451-3839
Mailing Address - Fax:
Practice Address - Street 1:150 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1103
Practice Address - Country:US
Practice Address - Phone:909-599-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3897628106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician