=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922717818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY GUILLEN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1328 NW 6TH ST
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-476-4010
-----------------------------------------------------
Fax | 541-474-6310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 774
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97528-0066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-476-4010
-----------------------------------------------------
Fax | 541-474-6310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 9544
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------