MEDICARE: BETHEL VERCRUYSSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ASW 35906	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ASW 35906	OTHER	CA	CLINICAL SOCIAL WORKER

General Provider Information

NPI Number	:	1316376262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHEL VERCRUYSSEN

Provider Business Mailing Address
First Line	:	PO BOX 15
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-0015
Country	:	US
Telephone Number	:	916-206-9563
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 APPALOOSA CT
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-5863
Country	:	US
Telephone Number	:	916-206-9563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2013
Last Update Date	:	11/01/2013

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Directions to “ BETHEL VERCRUYSSEN ” Practice Location

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