Provider Demographics
NPI:1699180059
Name:SEGURA, BETTIE
Entity Type:Individual
Prefix:
First Name:BETTIE
Middle Name:
Last Name:SEGURA
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 1:12600 N 113TH AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363-1162
Mailing Address - Country:US
Mailing Address - Phone:623-972-4033
Mailing Address - Fax:
Practice Address - Street 1:12600 N 113TH AVE BLDG A
Practice Address - Street 2:
Practice Address - City:YOUNGTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85363-1162
Practice Address - Country:US
Practice Address - Phone:623-972-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1541224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant