Healthcare Provider Details

I. General information

NPI: 1528808144
Provider Name (Legal Business Name): BETHANY DERBY MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 SAINT BERNARD AVE
NEW ORLEANS LA
70116-1417
US

IV. Provider business mailing address

1418 SAINT BERNARD AVE
NEW ORLEANS LA
70116-1417
US

V. Phone/Fax

Practice location:
  • Phone: 814-853-9005
  • Fax:
Mailing address:
  • Phone: 814-853-9005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC12022-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7738
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: