Healthcare Provider Details

I. General information

NPI: 1700244837
Provider Name (Legal Business Name): KIMBERLY BETHEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 CHILDRENS WAY
ENTERPRISE FL
32725-8135
US

IV. Provider business mailing address

110 QUEENS CT
SANFORD FL
32771-7766
US

V. Phone/Fax

Practice location:
  • Phone: 386-668-4774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: