Provider Demographics
NPI:1316376262
Name:VERCRUYSSEN, BETHEL
Entity Type:Individual
Prefix:
First Name:BETHEL
Middle Name:
Last Name:VERCRUYSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-0015
Mailing Address - Country:US
Mailing Address - Phone:916-206-9563
Mailing Address - Fax:
Practice Address - Street 1:1325 APPALOOSA CT
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5863
Practice Address - Country:US
Practice Address - Phone:916-206-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 359061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW 35906OtherCLINICAL SOCIAL WORKER