Provider Demographics
NPI:1053926758
Name:LEE, BETHANY JOYANNA (BCABA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:JOYANNA
Last Name:LEE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 N BIRDSELL DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9307
Mailing Address - Country:US
Mailing Address - Phone:907-903-1949
Mailing Address - Fax:
Practice Address - Street 1:1175 N LEATHERLEAF LOOP STE C
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6527
Practice Address - Country:US
Practice Address - Phone:907-414-9554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AK200945106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician