Provider Demographics
NPI:1871157883
Name:YOUNG, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MDW
Mailing Address - Street 2:1100 WILFORD HALL LOOP BLDG. 4554
Mailing Address - City:JBSA-LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-292-1602
Mailing Address - Fax:
Practice Address - Street 1:59 MDW
Practice Address - Street 2:1100 WILFORD HALL LOOP BLDG. 4554
Practice Address - City:JBSA-LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:850-283-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical