Provider Demographics
NPI:1952983264
Name:TEDFORD, BETHANY JOY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JOY
Last Name:TEDFORD
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 1:3115 WOODLAND HILLS DR APT 708
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4668
Mailing Address - Country:US
Mailing Address - Phone:719-360-4082
Mailing Address - Fax:
Practice Address - Street 1:2233 ACADEMY PL STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1679
Practice Address - Country:US
Practice Address - Phone:719-597-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician