Provider Demographics
NPI:1477897973
Name:BETANCOURTH, ROBERTO WILLIAM (LMSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:WILLIAM
Last Name:BETANCOURTH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 111TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1343
Mailing Address - Country:US
Mailing Address - Phone:917-691-1075
Mailing Address - Fax:
Practice Address - Street 1:3410 111TH ST APT 2
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1343
Practice Address - Country:US
Practice Address - Phone:917-691-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086202-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker