Provider Demographics
NPI:1063395218
Name:BETHEA, QWEZIONE TYREE
Entity type:Individual
Prefix:
First Name:QWEZIONE
Middle Name:TYREE
Last Name:BETHEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SPRING ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 CROSS RD
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:08021-6804
Practice Address - Country:US
Practice Address - Phone:332-280-8569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071157477172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver