Provider Demographics
NPI:1689456717
Name:BETTENCOURT, GARY JOSEPH (SUDCC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOSEPH
Last Name:BETTENCOURT
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SYLVAN AVE STE C103
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1687
Mailing Address - Country:US
Mailing Address - Phone:209-758-7477
Mailing Address - Fax:
Practice Address - Street 1:1101 SYLVAN AVE STE C103
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1687
Practice Address - Country:US
Practice Address - Phone:209-758-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9127101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)