Provider Demographics
NPI:1548684475
Name:HEYDEL, BETHANY (LMT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HEYDEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21301 SE BOHNA PARK RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-8323
Mailing Address - Country:US
Mailing Address - Phone:503-780-3201
Mailing Address - Fax:
Practice Address - Street 1:21301 SE BOHNA PARK RD
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-8323
Practice Address - Country:US
Practice Address - Phone:503-780-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11728172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker