Provider Demographics
NPI:1609132786
Name:BETTENCOURT, LACIE (PTA)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:BETTENCOURT
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2398
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2398
Mailing Address - Country:US
Mailing Address - Phone:870-404-5299
Mailing Address - Fax:870-404-5299
Practice Address - Street 1:201 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3653
Practice Address - Country:US
Practice Address - Phone:807-404-5299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2392225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK2392OtherPTA LICENSE #