Provider Demographics
NPI:1134650690
Name:CARNEFIX, BETHANY DIAMOND (PT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:DIAMOND
Last Name:CARNEFIX
Suffix:
Gender:
Credentials:PT
Other - Prefix:MISS
Other - First Name:BETHANY
Other - Middle Name:N
Other - Last Name:DIAMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 860912
Mailing Address - Street 2:PROVIDER ENROLLMENT - RST
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0912
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0002
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60843631225100000X
OH0043402255A2300X
MN13751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13751OtherPHYSICAL THERAPY BOARD OF MINNESOTA
WAPT60843631OtherPHYSICAL THERAPY BOARD OF WASHINGTON
WA2098539Medicaid