Healthcare Provider Details

I. General information

NPI: 1164817151
Provider Name (Legal Business Name): BETHANY BRUNETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 RAMSEY WAY
DICKSON TN
37055-2198
US

IV. Provider business mailing address

1820 MEMORIAL CIR
CLARKSVILLE TN
37043-4539
US

V. Phone/Fax

Practice location:
  • Phone: 931-217-6596
  • Fax:
Mailing address:
  • Phone: 931-436-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000007115
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: