Provider Demographics
NPI:1881801843
Name:BETANCOURT, GEORGE (MSSW, LCSW)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:M
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT
Mailing Address - Street 2:STE 105
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:1423 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-2105
Practice Address - Country:US
Practice Address - Phone:608-280-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39780200Medicaid
MPMEMedicare UPIN