Provider Demographics
NPI:1629726237
Name:LI, BETTY MA
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:MA
Last Name:LI
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 1:6412 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6412 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1329
Practice Address - Country:US
Practice Address - Phone:727-766-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA81188225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist