Healthcare Provider Details

I. General information

NPI: 1912635210
Provider Name (Legal Business Name): CHRISTOPHER ERIC BETOW LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2022
Last Update Date: 08/13/2022
Certification Date: 08/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 S ONEIDA ST STE E
APPLETON WI
54915-1524
US

IV. Provider business mailing address

1931 S LAWE ST
APPLETON WI
54915-2406
US

V. Phone/Fax

Practice location:
  • Phone: 920-427-3005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12373-146
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT01443600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: