=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891054334
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHENE A. BABCOCK M.A.,M.F.T
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2012
-----------------------------------------------------
Last Update Date | 05/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2303 FLORENCITA AVE
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-243-7841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2303 FLORENCITA AVE
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-243-7841
-----------------------------------------------------
Fax | 818-243-7841
-----------------------------------------------------
=====================================================
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 | MFT34938
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------