Provider Demographics
NPI:1316139207
Name:BETANCOURT, DIANA M (MT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BETANCOURT
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 1:6915 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4238
Mailing Address - Country:US
Mailing Address - Phone:718-575-0300
Mailing Address - Fax:718-575-3559
Practice Address - Street 1:6915 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4238
Practice Address - Country:US
Practice Address - Phone:718-575-0300
Practice Address - Fax:718-575-3559
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist