Healthcare Provider Details

I. General information

NPI: 1275217481
Provider Name (Legal Business Name): MS. EILEEN ALEXANDRA BETANCOURTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W AMELIA ST
ORLANDO FL
32801-1129
US

IV. Provider business mailing address

306 TURNSTONE WAY
ORLANDO FL
32828-8475
US

V. Phone/Fax

Practice location:
  • Phone: 407-317-3200
  • Fax: 407-317-3200
Mailing address:
  • Phone: 407-928-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA15427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: