Healthcare Provider Details

I. General information

NPI: 1053134643
Provider Name (Legal Business Name): BETHANY KLEINHANS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETHANY ZRUCKY RCSWI

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 206A
SAINT AUGUSTINE FL
32080-3111
US

IV. Provider business mailing address

1513 LOW TIDE LOOP
ST AUGUSTINE FL
32080-2307
US

V. Phone/Fax

Practice location:
  • Phone: 904-420-0580
  • Fax:
Mailing address:
  • Phone: 507-272-3749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: