Healthcare Provider Details

I. General information

NPI: 1205654720
Provider Name (Legal Business Name): BETHANY LAWSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 N MAIN ST
MOUNTAIN GROVE MO
65711-1025
US

IV. Provider business mailing address

833 TURNBO RD
MARSHFIELD MO
65706-9070
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-5699
  • Fax: 417-926-5703
Mailing address:
  • Phone: 417-241-0185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2019027359
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: