=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497395867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY MCDONALD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 01/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 W BRUCE AVE
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85233-5404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-965-8198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 S GILBERT RD APT 2142
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-8012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-626-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-18126
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------