Healthcare Provider Details

I. General information

NPI: 1578153847
Provider Name (Legal Business Name): BETHANNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 WHARTON ST
PHILADELPHIA PA
19146-3942
US

IV. Provider business mailing address

1030 SECOND STREET PIKE
SOUTHAMPTON PA
18966-3955
US

V. Phone/Fax

Practice location:
  • Phone: 215-355-6500
  • Fax:
Mailing address:
  • Phone: 215-355-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RENEE MARIE NIX
Title or Position: DIRECTOR OF QA & COMP
Credential: LSW
Phone: 267-566-9041