Healthcare Provider Details

I. General information

NPI: 1609224955
Provider Name (Legal Business Name): IVELISSE BETANCOURT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6143 NW 181ST TERRACE CIR W
HIALEAH FL
33015-5626
US

IV. Provider business mailing address

6143 NW 181ST TERRACE CIR W
HIALEAH FL
33015-5626
US

V. Phone/Fax

Practice location:
  • Phone: 305-305-7165
  • Fax:
Mailing address:
  • Phone: 305-305-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: