Provider Demographics
NPI:1730758012
Name:WYBERT, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:WYBERT
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 1:1210 CONCANNON ST
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-1206
Mailing Address - Country:US
Mailing Address - Phone:302-373-3719
Mailing Address - Fax:
Practice Address - Street 1:1624 GRATZ BROWN ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1993
Practice Address - Country:US
Practice Address - Phone:302-373-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional