Provider Demographics
NPI:1225855588
Name:BETTINCOURT, KIMBERLY (MT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BETTINCOURT
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 S 13TH PL
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4581
Mailing Address - Country:US
Mailing Address - Phone:435-513-1421
Mailing Address - Fax:
Practice Address - Street 1:915 MAIN ST BLDG A
Practice Address - Street 2:
Practice Address - City:CLARKDALE
Practice Address - State:AZ
Practice Address - Zip Code:86324-0169
Practice Address - Country:US
Practice Address - Phone:435-513-1421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT24199225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist