Basic Information
| Provider Information | |||||||||
| NPI: | 1316422678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | BETHANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 S GARDEN WAY STE 250 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 10214707 | OR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.