Provider Demographics
NPI:1174999411
Name:WILSON, BETHEL MCMULLEN
Entity type:Individual
Prefix:
First Name:BETHEL
Middle Name:MCMULLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:MCMULLEN
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 SE 7TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4891
Mailing Address - Country:US
Mailing Address - Phone:352-795-4114
Mailing Address - Fax:352-563-2438
Practice Address - Street 1:255 SE 7TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4891
Practice Address - Country:US
Practice Address - Phone:352-795-4114
Practice Address - Fax:352-563-2438
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist