Provider Demographics
NPI:1548968852
Name:MOORE, BETHANY (CMHW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CMHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-5056
Mailing Address - Country:US
Mailing Address - Phone:307-885-9883
Mailing Address - Fax:
Practice Address - Street 1:389 ADAMS ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-5056
Practice Address - Country:US
Practice Address - Phone:307-885-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WYCMHW-0681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician