Provider Demographics
NPI:1295348597
Name:BETANCES, AMBER ALTAGRACIA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:ALTAGRACIA
Last Name:BETANCES
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11029 PURPLE MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2420
Mailing Address - Country:US
Mailing Address - Phone:917-846-7047
Mailing Address - Fax:
Practice Address - Street 1:11029 PURPLE MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2420
Practice Address - Country:US
Practice Address - Phone:813-485-4476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19413235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist