Provider Demographics
NPI:1689166472
Name:BETANCOURT, GLADYS (PT)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 E PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4302
Mailing Address - Country:US
Mailing Address - Phone:480-694-5177
Mailing Address - Fax:
Practice Address - Street 1:3663 E PAGE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4302
Practice Address - Country:US
Practice Address - Phone:480-694-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1359PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist