Healthcare Provider Details

I. General information

NPI: 1952671216
Provider Name (Legal Business Name): MARY BETSELLIE CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date: 10/13/2022
Reactivation Date: 11/22/2022

III. Provider practice location address

2150 W ALAMEDA RD UNIT 1222
PHOENIX AZ
85085-1937
US

IV. Provider business mailing address

2150 W ALAMEDA RD UNIT 1222
PHOENIX AZ
85085-1937
US

V. Phone/Fax

Practice location:
  • Phone: 631-901-4174
  • Fax:
Mailing address:
  • Phone: 631-901-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number1129
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM259
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: