Provider Demographics
NPI:1053936336
Name:COGBURN, BETHANI (NCC, LCMHCA)
Entity type:Individual
Prefix:
First Name:BETHANI
Middle Name:
Last Name:COGBURN
Suffix:
Gender:F
Credentials:NCC, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 SAXONBURY WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-9437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1218 EAST BLVD STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6158
Practice Address - Country:US
Practice Address - Phone:704-912-1074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13192101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health