Healthcare Provider Details

I. General information

NPI: 1225564982
Provider Name (Legal Business Name): JOHN BETANCOURT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N 12TH AVE BLDG B
ARCADIA FL
34266-8752
US

IV. Provider business mailing address

101 RIVERFRONT BLVD STE 710
BRADENTON FL
34205-8812
US

V. Phone/Fax

Practice location:
  • Phone: 863-494-1242
  • Fax:
Mailing address:
  • Phone: 941-776-4000
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14279
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: