Healthcare Provider Details

I. General information

NPI: 1932080595
Provider Name (Legal Business Name): BETHANY MORGAN NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16941 N EAGLE RIVER LOOP RD
EAGLE RIVER AK
99577-7824
US

IV. Provider business mailing address

13818 HUNTERWOOD LN
EAGLE RIVER AK
99577-7022
US

V. Phone/Fax

Practice location:
  • Phone: 907-206-4421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-478280
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: