Basic Information
| Provider Information | |||||||||
| NPI: | 1386145472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETHELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ZACKARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1879 E FIR AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593238484 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1879 E FIR AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593238484 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 132252 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.