Provider Demographics
NPI:1386266278
Name:LACK, BETHANY (CSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LACK
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 LOUISVILLE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1202
Mailing Address - Country:US
Mailing Address - Phone:270-904-0055
Mailing Address - Fax:270-904-5110
Practice Address - Street 1:1990 LOUISVILLE RD STE 107
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1202
Practice Address - Country:US
Practice Address - Phone:270-904-0055
Practice Address - Fax:270-904-5110
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical