Healthcare Provider Details

I. General information

NPI: 1558804005
Provider Name (Legal Business Name): BETHANY MACEDO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETHANY LEMIEUX ATC

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 HAWTHORN ST
DARTMOUTH MA
02747-3729
US

IV. Provider business mailing address

13 JOHNSON ST
TAUNTON MA
02780-3606
US

V. Phone/Fax

Practice location:
  • Phone: 774-328-1590
  • Fax:
Mailing address:
  • Phone: 774-328-1590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number3030
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3030
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: