MEDICARE: BETHANY D. HENRY MED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	741464768	ID

General Provider Information

NPI Number	:	1104757988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY D. HENRY MED

Provider Business Mailing Address
First Line	:	714 JEFFERSON AVE
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1545
Country	:	US
Telephone Number	:	208-451-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 JEFFERSON AVE
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1545
Country	:	US
Telephone Number	:	208-451-3632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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Directions to “ BETHANY D. HENRY MED” Practice Location

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