Provider Demographics
NPI:1487066916
Name:LOVERN, BETHANY ANNE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ANNE
Last Name:LOVERN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:BETHANY
Other - Middle Name:ANNE
Other - Last Name:CRANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 GOOSE CREEK DR
Mailing Address - Street 2:#3323
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-8345
Mailing Address - Country:US
Mailing Address - Phone:317-691-5603
Mailing Address - Fax:
Practice Address - Street 1:2 GOOSE CREEK DR
Practice Address - Street 2:#3323
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-8345
Practice Address - Country:US
Practice Address - Phone:317-691-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011953235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist