Provider Demographics
NPI:1487151262
Name:GRISMORE, BETHANY BLEDSOE
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:BLEDSOE
Last Name:GRISMORE
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 1:16040 NW EDWARD CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7209
Mailing Address - Country:US
Mailing Address - Phone:503-764-7488
Mailing Address - Fax:
Practice Address - Street 1:14600 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5442
Practice Address - Country:US
Practice Address - Phone:503-645-3581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator