Healthcare Provider Details

I. General information

NPI: 1790286532
Provider Name (Legal Business Name): BETHANY RAY WILSON APSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY RAY RUCKEL AS, CCHW, TCM, APSS

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 WALLER AVE STE 250
LEXINGTON KY
40504-2915
US

IV. Provider business mailing address

3677 BEATEN PATH
LEXINGTON KY
40509-8564
US

V. Phone/Fax

Practice location:
  • Phone: 859-562-1770
  • Fax:
Mailing address:
  • Phone: 859-209-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberKCCHW12307238
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1164221
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: