Healthcare Provider Details

I. General information

NPI: 1447175914
Provider Name (Legal Business Name): SHALEASE BETHEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 IRVIN WAY STE 201
DECATUR GA
30030-1724
US

IV. Provider business mailing address

1572 HARDEE ST NE APT 6D
ATLANTA GA
30307-2865
US

V. Phone/Fax

Practice location:
  • Phone: 762-218-4650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-747781
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: