Provider Demographics
NPI:1124239629
Name:WILSON-PAUL, BETHANY (LISW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:WILSON-PAUL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 SOUTH BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044
Mailing Address - Country:US
Mailing Address - Phone:513-424-0921
Mailing Address - Fax:513-424-4810
Practice Address - Street 1:1659 SOUTH BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044
Practice Address - Country:US
Practice Address - Phone:513-424-0921
Practice Address - Fax:513-424-4810
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-9409101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW38111Medicare PIN