Healthcare Provider Details

I. General information

NPI: 1902128457
Provider Name (Legal Business Name): BETHANY LEIGH SNIPES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 MILL STREET
COVINGTON GA
30030
US

IV. Provider business mailing address

1224 CRYSTAL DR
CLARKSVILLE TN
37042-7262
US

V. Phone/Fax

Practice location:
  • Phone: 706-338-7076
  • Fax:
Mailing address:
  • Phone: 706-338-7076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004479
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: