Provider Demographics
NPI:1124785589
Name:MILLER, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:MILLER
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 1:10854 196TH AVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9422
Mailing Address - Country:US
Mailing Address - Phone:231-629-8139
Mailing Address - Fax:
Practice Address - Street 1:5856 FEDERAL RD
Practice Address - Street 2:
Practice Address - City:HOWARD CITY
Practice Address - State:MI
Practice Address - Zip Code:49329-8635
Practice Address - Country:US
Practice Address - Phone:616-608-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health