Provider Demographics
NPI:1356823512
Name:BETANCOURT, EVELYN (BA)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 S RECORD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1924
Mailing Address - Country:US
Mailing Address - Phone:323-354-2379
Mailing Address - Fax:
Practice Address - Street 1:3360 N HIGHWAY 59 STE K
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-9405
Practice Address - Country:US
Practice Address - Phone:209-725-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA100557101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program