Provider Demographics
NPI:1427404375
Name:BETANCOURT, JUAN CARLOS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:BETANCOURT
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 1:3164 SOUTHMOST RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-4791
Mailing Address - Country:US
Mailing Address - Phone:956-466-1245
Mailing Address - Fax:956-544-2569
Practice Address - Street 1:835 W PRICE RD STE 7
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8715
Practice Address - Country:US
Practice Address - Phone:956-455-1869
Practice Address - Fax:956-544-2569
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116919225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist