Provider Demographics
NPI:1629896121
Name:HARRISON, BETHANY NICHOLE (LPC-IT)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:NICHOLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 PITTCO RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8759
Mailing Address - Country:US
Mailing Address - Phone:920-501-0670
Mailing Address - Fax:
Practice Address - Street 1:2330 MEADOW PARK DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6941
Practice Address - Country:US
Practice Address - Phone:920-490-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8141-266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional