Healthcare Provider Details

I. General information

NPI: 1578877999
Provider Name (Legal Business Name): MS. LIZA CONCEICAO BETTENCOURT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GOODRICH BLVD
COMMERCE CA
90022-5103
US

IV. Provider business mailing address

350 S MADISON AVE APT 317
PASADENA CA
91101-3397
US

V. Phone/Fax

Practice location:
  • Phone: 323-832-9795
  • Fax:
Mailing address:
  • Phone: 408-427-2975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: