Provider Demographics
NPI:1043725120
Name:BETZ, MICHELLE ANN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:BETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130A POLAR WIND CT
Mailing Address - Street 2:
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-3148
Mailing Address - Country:US
Mailing Address - Phone:701-340-4035
Mailing Address - Fax:
Practice Address - Street 1:203 SANTA CLAUS LN
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-6055
Practice Address - Country:US
Practice Address - Phone:701-340-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician