Provider Demographics
NPI:1154175628
Name:GORTER, BETHANY GRACE
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:GRACE
Last Name:GORTER
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 1:50 FRANKLIN ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1008
Mailing Address - Country:US
Mailing Address - Phone:551-206-6548
Mailing Address - Fax:
Practice Address - Street 1:50 FRANKLIN ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1008
Practice Address - Country:US
Practice Address - Phone:551-206-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical