Provider Demographics
NPI:1306357207
Name:BETZ, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 W SARAH MYERS DR
Mailing Address - Street 2:
Mailing Address - City:WEST TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47885-9507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4590 W SARAH MYERS DR
Practice Address - Street 2:
Practice Address - City:WEST TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47885-9507
Practice Address - Country:US
Practice Address - Phone:631-487-5667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002632A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer