Healthcare Provider Details

I. General information

NPI: 1699819904
Provider Name (Legal Business Name): CONNIE JEANNE BETTICH L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 US 27 N
LAKE PLACID FL
33852-7948
US

IV. Provider business mailing address

2120 BURNING TREE CIR
SEBRING FL
33872-4021
US

V. Phone/Fax

Practice location:
  • Phone: 863-465-3777
  • Fax: 863-699-4339
Mailing address:
  • Phone: 863-471-0586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH5082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: