Provider Demographics
NPI:1699581975
Name:HAFENSTEIN-RIEGE, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HAFENSTEIN-RIEGE
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:N6287 COUNTY ROAD G
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9687
Mailing Address - Country:US
Mailing Address - Phone:920-219-2324
Mailing Address - Fax:
Practice Address - Street 1:405 E FOREST ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3707
Practice Address - Country:US
Practice Address - Phone:920-219-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7845226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty