Basic Information
| Provider Information | |||||||||
| NPI: | 1588019814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANAN | ||||||||
| FirstName: | BETHANY | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 519 LAKEVIEW ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328046822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073426650 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3730 GATLIN WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328127610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2016 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 103K00000X | 0-16-7460 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.