Healthcare Provider Details

I. General information

NPI: 1386436285
Provider Name (Legal Business Name): BETHANEE MIRANDA TOVAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E HUNTLAND DR STE 320
AUSTIN TX
78752-3741
US

IV. Provider business mailing address

3100 SCOFIELD RIDGE PKWY APT 1109
AUSTIN TX
78727-6567
US

V. Phone/Fax

Practice location:
  • Phone: 512-201-4501
  • Fax:
Mailing address:
  • Phone: 512-636-7251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number95713
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: