Provider Demographics
NPI:1184282238
Name:BETHEA, DETRICE
Entity type:Individual
Prefix:MRS
First Name:DETRICE
Middle Name:
Last Name:BETHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 SUMMIT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7603
Mailing Address - Country:US
Mailing Address - Phone:803-705-1885
Mailing Address - Fax:
Practice Address - Street 1:801 N PIKE W
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29153-1906
Practice Address - Country:US
Practice Address - Phone:803-775-9364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health