Provider Demographics
NPI:1457597668
Name:FUENTES, BETZAIDA (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:BETZAIDA
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6908
Mailing Address - Country:US
Mailing Address - Phone:954-559-1221
Mailing Address - Fax:857-244-6299
Practice Address - Street 1:214 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6908
Practice Address - Country:US
Practice Address - Phone:617-477-4050
Practice Address - Fax:857-244-6299
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA334103K00000X
PR0972103TC0700X
1-10-6937103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303414Medicaid