Provider Demographics
NPI:1194103606
Name:BETTERS-BLACK, TRICIA (LCSW)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:BETTERS-BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SW 11TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2554
Mailing Address - Country:US
Mailing Address - Phone:239-313-1920
Mailing Address - Fax:
Practice Address - Street 1:1514 NE 11TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1547
Practice Address - Country:US
Practice Address - Phone:239-313-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-16
Last Update Date:2015-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW128081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical