Provider Demographics
NPI:1154757953
Name:SIMON, BETHANY DARLENE
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:DARLENE
Last Name:SIMON
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 1:633 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1157
Mailing Address - Country:US
Mailing Address - Phone:502-309-2408
Mailing Address - Fax:502-771-4283
Practice Address - Street 1:633 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1157
Practice Address - Country:US
Practice Address - Phone:502-309-2408
Practice Address - Fax:502-771-4283
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY162423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100310790Medicaid