Provider Demographics
NPI:1952671216
Name:BETSELLIE, MARY (CPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BETSELLIE
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 W ALAMEDA RD UNIT 1222
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-1937
Mailing Address - Country:US
Mailing Address - Phone:631-901-4174
Mailing Address - Fax:
Practice Address - Street 1:2150 W ALAMEDA RD UNIT 1222
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-1937
Practice Address - Country:US
Practice Address - Phone:631-901-4174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2023-03-22
Deactivation Date:2022-10-13
Deactivation Code:
Reactivation Date:2022-11-22
Provider Licenses
StateLicense IDTaxonomies
NY1129374J00000X
AZLM259176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula