Basic Information
| Provider Information | |||||||||
| NPI: | 1750914636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETHANY | ||||||||
| FirstName: | CHLOE | ||||||||
| MiddleName: | MERRITT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2624 CHAPEL HILL RD APT A | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277071958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439919074 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3325 DURHAM CHAPEL HILL BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194439905 | ||||||||
| FaxNumber: | 9848880913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-25653 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | P014215 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.