Healthcare Provider Details

I. General information

NPI: 1396051637
Provider Name (Legal Business Name): JUSTIN NICHOLAS BETHONEY N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 SW SHEVLIN HIXON DR STE 102
BEND OR
97702-3232
US

IV. Provider business mailing address

151 SW SHEVLIN HIXON DR STE 102
BEND OR
97702-3232
US

V. Phone/Fax

Practice location:
  • Phone: 458-206-6251
  • Fax: 224-215-3993
Mailing address:
  • Phone: 458-206-6251
  • Fax: 224-215-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN2264824
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95001312
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201501392NP-PP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN2264824
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: