Provider Demographics
NPI:1609316744
Name:BETANCOURT, LYDA (BS, MBA)
Entity Type:Individual
Prefix:
First Name:LYDA
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:BS, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 W 84TH ST STE D110
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4932
Mailing Address - Country:US
Mailing Address - Phone:305-825-4320
Mailing Address - Fax:305-675-3640
Practice Address - Street 1:3414 W 84TH ST STE D110
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4932
Practice Address - Country:US
Practice Address - Phone:305-825-4320
Practice Address - Fax:305-675-3640
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator