=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326796707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY NICOLE DAVIS MSBS, LMFT-CANDIDATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2022
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 SW 38TH ST
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-6912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-5780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 283 NE CREEKSIDE DR
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73538-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-307-4698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------