Provider Demographics
NPI:1427465277
Name:THEODORE, BETHANY (LCSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7614
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19714-7614
Mailing Address - Country:US
Mailing Address - Phone:484-602-9681
Mailing Address - Fax:
Practice Address - Street 1:99 ALMADEN BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-6489
Practice Address - Country:US
Practice Address - Phone:707-527-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2023-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW59950101YM0800X
CA907451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health