Basic Information
| Provider Information | |||||||||
| NPI: | 1912384967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETANCOURT | ||||||||
| FirstName: | ROXANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 ATLANTIC AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145879007 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 CONCORD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945204969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102688120 | ||||||||
| FaxNumber: | 6193747134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-15-18180 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.