Basic Information
| Provider Information | |||||||||
| NPI: | 1891349296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETANCOURT | ||||||||
| FirstName: | ROXANA | ||||||||
| MiddleName: | CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6739 HOLLY HEATH DR | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335788406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865054449 | ||||||||
| FaxNumber: | 7866673733 | ||||||||
| Practice Location | |||||||||
| Address1: | 6739 HOLLY HEATH DR | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335788406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865054449 | ||||||||
| FaxNumber: | 7866673733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2019 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 106S00000X | 16-14094 | FL | N |
No ID Information.