Basic Information
| Provider Information | |||||||||
| NPI: | 1861620643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUEBNER | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLDER | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7300 E INDIANA ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 4421 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477103621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127593001 | ||||||||
| FaxNumber: | 8124019013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009912A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 00000064558 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 200951100 | 05 | IN | MEDICAID | 000000622157 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |