Provider Demographics
NPI:1386145472
Name:BETHELL, MATTHEW ZACKARY (BA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ZACKARY
Last Name:BETHELL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 E FIR AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3861
Mailing Address - Country:US
Mailing Address - Phone:559-323-8484
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:1879 E FIR AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3861
Practice Address - Country:US
Practice Address - Phone:559-323-8484
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132252106H00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst