Healthcare Provider Details

I. General information

NPI: 1801990072
Provider Name (Legal Business Name): BETHANY L CONKLIN L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 EUCLID ROAD
GRANDVIEW WA
98930-1160
US

IV. Provider business mailing address

171 SAND HILL RD
GRANDVIEW WA
98930-9451
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-7888
  • Fax:
Mailing address:
  • Phone: 509-882-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: