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General NPI Number Information
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NPI Number | 1942887898
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Entity Type | Individual
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Provider Name | MRS. BETHANY JEAN CARLSON
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Gender | Female
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Dates
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Enumeration Date | 03/26/2021
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Last Update Date | 03/26/2021
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Provider Practice Location Address
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Address Line | 1000 SAN GABRIEL BLVD STE 200
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City | ROSEMEAD
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State | CA
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Zip | 91770-4394
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Country | US
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Telephone | 232-498-2231
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Fax | 323-486-1440
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Provider Business Mailing Address
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Address Line | 13865 REPOSA CT
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City | EASTVALE
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State | CA
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Zip | 92880-3268
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Country | US
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Telephone | 951-833-3233
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Fax | 323-486-1440
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | 236417
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License Number State | CA
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