Provider Demographics
NPI:1902653371
Name:BETTENCOURT, KELLY ELISA (MED, ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELISA
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 ATHENS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-7006
Mailing Address - Country:US
Mailing Address - Phone:559-970-3811
Mailing Address - Fax:
Practice Address - Street 1:1560 N MINNEWAWA AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-7600
Practice Address - Country:US
Practice Address - Phone:559-970-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA069926092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer