Healthcare Provider Details

I. General information

NPI: 1194900027
Provider Name (Legal Business Name): PETRA BETANCOURT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 LAUREL CANYON BLVD. SUITE #116
MISSION HILLS CA
91430
US

IV. Provider business mailing address

4117 MCLAUGHLIN AVE APT 2
LOS ANGELES CA
90066-5447
US

V. Phone/Fax

Practice location:
  • Phone: 818-361-5030
  • Fax: 818-361-1764
Mailing address:
  • Phone: 310-869-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number84544
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: