MEDICARE: MARISA RENEE BETHEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101YA0400X	OTHER		TAXONOMY

General Provider Information

NPI Number	:	1376214460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA RENEE BETHEL

Provider Business Mailing Address
First Line	:	3248 VANDEVER AVE
Second Line	:
City	:	PEKIN
State	:	IL
Zip	:	61554-6274
Country	:	US
Telephone Number	:	309-347-5522
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 W WASHINGTON ST
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2532
Country	:	US
Telephone Number	:	309-694-6462
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	09/28/2021

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