Provider Demographics
NPI:1699149823
Name:GIVENS, MARY BETHANY KYLENE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETHANY KYLENE
Last Name:GIVENS
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 1:7717 N ORANGE PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9323
Mailing Address - Country:US
Mailing Address - Phone:330-398-2367
Mailing Address - Fax:
Practice Address - Street 1:7717 N ORANGE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9323
Practice Address - Country:US
Practice Address - Phone:330-398-2367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-27
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0199811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical