Provider Demographics
NPI:1801210398
Name:BRUNN, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BRUNN
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 1:655 WOODDELL DR
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-4151
Mailing Address - Country:US
Mailing Address - Phone:321-576-6405
Mailing Address - Fax:
Practice Address - Street 1:4024 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 9646101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health