Healthcare Provider Details

I. General information

NPI: 1174477368
Provider Name (Legal Business Name): BETHANY N DEHAVEN LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E 15TH ST STE 10
VANCOUVER WA
98663-3451
US

IV. Provider business mailing address

404 E 15TH ST STE 10
VANCOUVER WA
98663-3451
US

V. Phone/Fax

Practice location:
  • Phone: 360-281-1042
  • Fax:
Mailing address:
  • Phone: 360-281-1042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSYC.PY.70044683
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: