Provider Demographics
NPI:1558024067
Name:BETANCOURT, LISIEL
Entity Type:Individual
Prefix:
First Name:LISIEL
Middle Name:
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 1:4649 PONCE DE LEON BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2121
Mailing Address - Country:US
Mailing Address - Phone:786-536-9714
Mailing Address - Fax:786-536-9833
Practice Address - Street 1:4649 PONCE DE LEON BLVD STE 404
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2121
Practice Address - Country:US
Practice Address - Phone:786-536-9714
Practice Address - Fax:786-536-9833
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM102823104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker