Healthcare Provider Details

I. General information

NPI: 1467225490
Provider Name (Legal Business Name): BETHANY MARIE WORLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 PROSPERITY LAKE DR UNIT 101
ST AUGUSTINE FL
32092-5045
US

IV. Provider business mailing address

260 HICKORY HOLLOW DR S
JACKSONVILLE FL
32225-3081
US

V. Phone/Fax

Practice location:
  • Phone: 904-370-3420
  • Fax:
Mailing address:
  • Phone: 904-412-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: