Healthcare Provider Details

I. General information

NPI: 1508306994
Provider Name (Legal Business Name): CANDICE ELIZABETH BETKE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

IV. Provider business mailing address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

V. Phone/Fax

Practice location:
  • Phone: 313-262-1172
  • Fax: 313-831-4651
Mailing address:
  • Phone: 313-262-1172
  • Fax: 313-831-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number4704201365
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: