Healthcare Provider Details

I. General information

NPI: 1720631807
Provider Name (Legal Business Name): MARTHA ROSE HALL BETHEA MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 N 1200 E
HEBER CITY UT
84032-3404
US

IV. Provider business mailing address

1805 N 1200 E
HEBER CITY UT
84032-3404
US

V. Phone/Fax

Practice location:
  • Phone: 719-644-6950
  • Fax:
Mailing address:
  • Phone: 719-644-6950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0020883
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14230500-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: