Provider Demographics
NPI:1801927249
Name:BETANCOURT, ANA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:BETANCOURT
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 1:200 BROADSOUND AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3751
Mailing Address - Country:US
Mailing Address - Phone:617-331-3814
Mailing Address - Fax:617-568-9778
Practice Address - Street 1:1 MONMOUTH SQ
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1319
Practice Address - Country:US
Practice Address - Phone:617-569-4561
Practice Address - Fax:617-568-9778
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4712101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM1187OtherBLUE CROSS BLUE SHIELD