Provider Demographics
NPI:1316483209
Name:THACKER, BETHANY MIRIYA (LCSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:MIRIYA
Last Name:THACKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 ATHENS WAY STE 240
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1311
Mailing Address - Country:US
Mailing Address - Phone:833-208-7770
Mailing Address - Fax:
Practice Address - Street 1:3200 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7528
Practice Address - Country:US
Practice Address - Phone:860-933-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016001149104100000X
NCC0114481041C0700X
FLSW215861041C0700X
SC137161041C0700X
IA1008061041C0700X
NV8936-C1041C0700X
VA09040106731041C0700X
TX1045931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker