=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346937414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4BETTIES ANGELS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2023
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 14TH ST NE STE D
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44714-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-415-8924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1613 2ND ST NE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44704-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-371-8985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DE-SHAWNAY BETTIEANA-TANIESHA DANIELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-371-8985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------