Provider Demographics
NPI:1568858389
Name:BETHAY, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:BETHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1248
Mailing Address - Country:US
Mailing Address - Phone:617-823-4538
Mailing Address - Fax:
Practice Address - Street 1:11350 RANDOM HILLS RD
Practice Address - Street 2:SUITE 240
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6044
Practice Address - Country:US
Practice Address - Phone:703-537-0688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-13-13016103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst