Basic Information
| Provider Information | |||||||||
| NPI: | 1508265281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTANO | ||||||||
| FirstName: | HARRIET | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST FL ST2 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088569510 | ||||||||
| FaxNumber: | 5088531907 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 GOLD STAR BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088569510 | ||||||||
| FaxNumber: | 5088531907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2014 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4682 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA00892600 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 110012858A | 05 | MA | MEDICAID |