Provider Demographics
NPI:1891386421
Name:CRISP, BETHANY ANNE (LLP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
Last Name:CRISP
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:ANNE
Other - Last Name:HEIDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TLLP
Mailing Address - Street 1:2450 PERRY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9210
Mailing Address - Country:US
Mailing Address - Phone:248-989-6128
Mailing Address - Fax:
Practice Address - Street 1:189 W CLARKSTON RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2892
Practice Address - Country:US
Practice Address - Phone:248-989-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007786103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling