Basic Information
Provider Information | |||||||||
NPI: | 1417010356 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRINTLE | ||||||||
FirstName: | BETHANY | ||||||||
MiddleName: | PEARL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 319 ROBIN RD | ||||||||
Address2: |   | ||||||||
City: | MOUNT AIRY | ||||||||
State: | NC | ||||||||
PostalCode: | 270303045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367192398 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 351 RIVERSIDE DR | ||||||||
Address2: |   | ||||||||
City: | MOUNT AIRY | ||||||||
State: | NC | ||||||||
PostalCode: | 270303850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367867079 | ||||||||
FaxNumber: | 3367866312 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 10/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4307 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 4307 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 6102321 | 05 | NC |   | MEDICAID |