Healthcare Provider Details

I. General information

NPI: 1770163412
Provider Name (Legal Business Name): BETHANY RENEE WURST LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 BRANSON HILLS PKWY STE 202
BRANSON MO
65616-4188
US

IV. Provider business mailing address

1232 BRANSON HILLS PKWY STE 202
BRANSON MO
65616-4188
US

V. Phone/Fax

Practice location:
  • Phone: 417-338-9355
  • Fax: 417-708-9797
Mailing address:
  • Phone: 417-338-9355
  • Fax: 417-708-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2019041532
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: