MEDICARE: MICHAEL BETTENCOURT LCSW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	111335	MA
2	1041C0700X	Clinical Social Worker	13063	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	461417	OTHER	MA	TUFTS PROVIDER NUMBER
3	P08075	OTHER	MA	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1891998720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL BETTENCOURT LCSW LLC

Provider Business Mailing Address
First Line	:	2805 E OAKLAND PARK BLVD # 174
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1813
Country	:	US
Telephone Number	:	617-869-6182
Fax Number	:

Provider Business Practice Location Address
First Line	:	2805 E OAKLAND PARK BLVD # 174
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1813
Country	:	US
Telephone Number	:	617-869-6182
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL BETTENCOURT
Credential	:	LCSW
Telephone Number	:	617-869-6182

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	03/19/2018

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