Provider Demographics
NPI:1326194424
Name:BETTERLEY, BRENT ALLAN (LP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALLAN
Last Name:BETTERLEY
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 278TH ST. W.
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:MN
Mailing Address - Zip Code:55010-0493
Mailing Address - Country:US
Mailing Address - Phone:651-460-6881
Mailing Address - Fax:612-863-8516
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0259103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist