Provider Demographics
NPI:1518424613
Name:BETZLER, GALEY (MA)
Entity Type:Individual
Prefix:
First Name:GALEY
Middle Name:
Last Name:BETZLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15011 LAGO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MURIETA
Mailing Address - State:CA
Mailing Address - Zip Code:95683-9513
Mailing Address - Country:US
Mailing Address - Phone:209-559-2655
Mailing Address - Fax:
Practice Address - Street 1:10400 FRICOT CITY ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9642
Practice Address - Country:US
Practice Address - Phone:209-559-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA057001447322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children