| Entity Name: | MICHAEL BETTENCOURT LCSW, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 17 Jan 2017 (8 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | L17000011280 |
| FEI/EIN Number | 81-5222411 |
| Address: | 2805 OAKLAND PARK BLVD #174, FORT LAUDERDALE, FL, 33306, US |
| Mail Address: | 2805 OAKLAND PARK BLVD #174, FORT LAUDERDALE, FL, 33306, US |
| ZIP code: | 33306 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891998720 | 2007-06-07 | 2018-03-19 | 2805 E OAKLAND PARK BLVD # 174, FORT LAUDERDALE, FL, 333061813, US | 2805 E OAKLAND PARK BLVD # 174, FORT LAUDERDALE, FL, 333061813, US | |||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 617-869-6182 |
Authorized person
| Name | MR. MICHAEL BETTENCOURT |
| Role | PRESIDENT |
| Phone | 6178696182 |
Taxonomy
| Taxonomy Code | 1041C0700X - Clinical Social Worker |
| License Number | 111335 |
| State | MA |
| Is Primary | No |
| Taxonomy Code | 1041C0700X - Clinical Social Worker |
| License Number | 13063 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1852612 |
| State | MA |
| Issuer | TUFTS PROVIDER NUMBER |
| Number | 461417 |
| State | MA |
| Issuer | BCBS PROVIDER NUMBER |
| Number | P08075 |
| State | MA |
| Name | Role | Address |
|---|---|---|
| BETTENCOURT MICHAEL LCSW | Agent | 2805 OAKLAND PARK BLVD #174, FORT LAUDERDALE, FL, 33306 |
| Name | Role | Address |
|---|---|---|
| BETTENCOURT MICHAEL LCSW | Manager | 2805 OAKLAND PARK BLVD #174, FORT LAUDERDALE, FL, 33306 |
| Name | Role | Address |
|---|---|---|
| BETTENCOURT MICHAEL LCSW | President | 2805 OAKLAND PARK BLVD #174, FORT LAUDERDALE, FL, 33306 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2018-04-27 |
| Florida Limited Liability | 2017-01-17 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
