Healthcare Provider Details

I. General information

NPI: 1710691951
Provider Name (Legal Business Name): BETHANY ROSE KOEN RBT, QASP-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 S PRAIRIE AVE
PUEBLO CO
81005-2307
US

IV. Provider business mailing address

3625 CITADEL DR S
COLORADO SPRINGS CO
80909-5320
US

V. Phone/Fax

Practice location:
  • Phone: 719-569-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-209998
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number21903
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: