Basic Information
| Provider Information | |||||||||
| NPI: | 1457597783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLEARY | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | ASHTON | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5210 CORPORATE CENTER CT NE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604558155 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5210 CORPORATE CENTER LOOP SE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985035952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604558155 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00023986 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1043MC | 01 | WA | REGENCE | OTHER | 1047MC | 01 | WA | REGENCE | OTHER | 1044MC | 01 | WA | REGENCE | OTHER | 1046MC | 01 | WA | REGENCE | OTHER | 0250028 | 01 | WA | DEPT OF L&I | OTHER | 1048MC | 01 | WA | REGENCE | OTHER |