Provider Demographics
NPI:1891998720
Name:MICHAEL BETTENCOURT LCSW LLC
Entity Type:Organization
Organization Name:MICHAEL BETTENCOURT LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTENCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:617-869-6182
Mailing Address - Street 1:2805 E OAKLAND PARK BLVD # 174
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1813
Mailing Address - Country:US
Mailing Address - Phone:617-869-6182
Mailing Address - Fax:
Practice Address - Street 1:2805 E OAKLAND PARK BLVD # 174
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1813
Practice Address - Country:US
Practice Address - Phone:617-869-6182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1113351041C0700X
FL130631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852612Medicaid
MA461417OtherTUFTS PROVIDER NUMBER
MAP08075OtherBCBS PROVIDER NUMBER
MA1852612Medicaid