Provider Demographics
NPI:1508945874
Name:PEREZ-BETANCOURT, MIRTA (LPC)
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:PEREZ-BETANCOURT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 NORRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19403-5133
Mailing Address - Country:US
Mailing Address - Phone:610-334-2200
Mailing Address - Fax:610-630-0426
Practice Address - Street 1:207 E MAIN ST
Practice Address - Street 2:OFC 5
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-5068
Practice Address - Country:US
Practice Address - Phone:610-334-2200
Practice Address - Fax:610-630-0426
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026945490001Medicaid