Provider Demographics
NPI:1518518273
Name:BETANCOURT, OLIVIA JACQUELINE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JACQUELINE
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15201 SPANGLER LN
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-6704
Mailing Address - Country:US
Mailing Address - Phone:956-226-9936
Mailing Address - Fax:
Practice Address - Street 1:1005 E 10TH ST STE B
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-5133
Practice Address - Country:US
Practice Address - Phone:956-969-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356212355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty