Provider Demographics
NPI:1275924334
Name:BETTIS, TANOA
Entity Type:Individual
Prefix:
First Name:TANOA
Middle Name:
Last Name:BETTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330
Mailing Address - Country:US
Mailing Address - Phone:215-590-7555
Mailing Address - Fax:215-590-7387
Practice Address - Street 1:4009 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330
Practice Address - Country:US
Practice Address - Phone:215-590-7555
Practice Address - Fax:215-590-7387
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055720001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical