Provider Demographics
NPI:1699893883
Name:TRAMMELL, BETH A (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:TRAMMELL
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2264
Mailing Address - Country:US
Mailing Address - Phone:765-284-0043
Mailing Address - Fax:765-284-4112
Practice Address - Street 1:1904 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2264
Practice Address - Country:US
Practice Address - Phone:765-284-0443
Practice Address - Fax:765-284-4112
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042638A103TC0700X, 103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN201089430Medicaid
IN100270530AMedicaid
IN150074Medicare PIN