Provider Demographics
NPI:1023300092
Name:NORDBY, BETHANY ROSE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ROSE
Last Name:NORDBY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3770
Mailing Address - Country:US
Mailing Address - Phone:218-454-4065
Mailing Address - Fax:218-454-1024
Practice Address - Street 1:823 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3770
Practice Address - Country:US
Practice Address - Phone:218-454-4065
Practice Address - Fax:218-454-1024
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN181681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical