Provider Demographics
NPI:1588315451
Name:BETHUNE, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BETHUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 PALM LAKE DR APT 302
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-0905
Mailing Address - Country:US
Mailing Address - Phone:404-472-7282
Mailing Address - Fax:
Practice Address - Street 1:6266 DUPONT STATION CT E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2567
Practice Address - Country:US
Practice Address - Phone:904-745-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health