Provider Demographics
NPI:1992998454
Name:RAY, BETHANY MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:MARIE
Last Name:RAY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9164
Mailing Address - Country:US
Mailing Address - Phone:417-693-6816
Mailing Address - Fax:
Practice Address - Street 1:1114 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9164
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:888-550-3518
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-19
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004023139235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267638Medicare Oscar/Certification