Healthcare Provider Details

I. General information

NPI: 1497585590
Provider Name (Legal Business Name): KEISHA M BETANCOURT FELICES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PARK PLACE BLVD STE C1
KISSIMMEE FL
34741-2358
US

IV. Provider business mailing address

2301 5TH ST
SAINT CLOUD FL
34769-2665
US

V. Phone/Fax

Practice location:
  • Phone: 407-385-0728
  • Fax:
Mailing address:
  • Phone: 321-337-5105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-366774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: