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General NPI Number Information
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NPI Number | 1609132786
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Entity Type | Individual
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Provider Name | LACIE BETTENCOURT PTA
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Gender | Female
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 201 N COLLEGE ST
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653-3653
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Country | US
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Telephone | 807-404-5299
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2398
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City | MOUNTAIN HOME
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State | AR
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Zip | 72654-2398
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Country | US
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Telephone | 870-404-5299
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Fax | 870-404-5299
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2392
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License Number State | AK
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