Provider Demographics
NPI:1194886804
Name:BETHEA, WANDA FELECIA (BACHEORS PSYCHOLOGY)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:FELECIA
Last Name:BETHEA
Suffix:
Gender:F
Credentials:BACHEORS PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 RYER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-1104
Mailing Address - Country:US
Mailing Address - Phone:718-960-0674
Mailing Address - Fax:718-563-8598
Practice Address - Street 1:2250 RYER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-1104
Practice Address - Country:US
Practice Address - Phone:718-960-0674
Practice Address - Fax:718-563-8598
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator