Provider Demographics
NPI:1932584844
Name:BETHEA, TENICIA LASEAN (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:TENICIA
Middle Name:LASEAN
Last Name:BETHEA
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-7434
Mailing Address - Country:US
Mailing Address - Phone:269-519-6693
Mailing Address - Fax:
Practice Address - Street 1:1485 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5711
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:269-927-1326
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68510984371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty