Provider Demographics
NPI:1881279719
Name:BETTENCOURT, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BETTENCOURT
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 1:1100 KANSAS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1596
Mailing Address - Country:US
Mailing Address - Phone:209-579-1151
Mailing Address - Fax:
Practice Address - Street 1:3131 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-7595
Practice Address - Country:US
Practice Address - Phone:209-410-4761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA11839172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)