Healthcare Provider Details

I. General information

NPI: 1467012872
Provider Name (Legal Business Name): BETHANY WYSOCKI AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 UPLAND LN N
MAPLE GROVE MN
55369-4485
US

IV. Provider business mailing address

9824 CHESTNUT LN
INDIANAPOLIS IN
46239-9363
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-1440
  • Fax:
Mailing address:
  • Phone: 317-679-5420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: