Basic Information
| Provider Information | |||||||||
| NPI: | 1871095596 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHANY A. OWENS, LSCSW | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHANY A. OWENS, LSCSW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17053 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672170053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169443940 | ||||||||
| FaxNumber: | 3169460694 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N WOODLAWN ST STE 30 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672084333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166129223 | ||||||||
| FaxNumber: | 3166129223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | SWAYZE | ||||||||
| AuthorizedOfficialFirstName: | LORRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3169443940 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4768 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4768 | 01 | KS | STATE LICENSE | OTHER | 201109570B | 05 | KS | MEDICAID |