Healthcare Provider Details

I. General information

NPI: 1285207696
Provider Name (Legal Business Name): BAILEY BETTENCOURT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 ARTESIA BLVD
HERMOSA BEACH CA
90254-2707
US

IV. Provider business mailing address

818 NORTH BLVD
OAK PARK IL
60301-1302
US

V. Phone/Fax

Practice location:
  • Phone: 310-893-3471
  • Fax:
Mailing address:
  • Phone: 866-727-8274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-77205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: