Provider Demographics
NPI:1538784012
Name:GOURLEY, BETHANY S (PHD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:S
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19855 OUTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2022
Mailing Address - Country:US
Mailing Address - Phone:313-359-1977
Mailing Address - Fax:
Practice Address - Street 1:19855 OUTER DR STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2022
Practice Address - Country:US
Practice Address - Phone:313-359-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019229103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist