=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952052532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMALA TERRAL BETHEA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2022
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 E GAY ST
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19380-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-597-4091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2024 W 9TH ST
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19013-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-597-2409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 49143601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------