Provider Demographics
NPI:1265866800
Name:BETANCOURT-KOLOSICK, NATHALIA (MA, PSYD, LMHC)
Entity Type:Individual
Prefix:
First Name:NATHALIA
Middle Name:
Last Name:BETANCOURT-KOLOSICK
Suffix:
Gender:F
Credentials:MA, PSYD, LMHC
Other - Prefix:
Other - First Name:NATHALIA
Other - Middle Name:
Other - Last Name:BETANCOURT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, PSYD,LMHC
Mailing Address - Street 1:2724 NE 15TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1975 E SUNRISE BLVD STE 517
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304
Practice Address - Country:US
Practice Address - Phone:954-945-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16155101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health