Provider Demographics
NPI:1033461611
Name:BERTOCH, SARA CUMMINGS (PHD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:CUMMINGS
Last Name:BERTOCH
Suffix:
Gender:F
Credentials:PHD
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 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:820 PRUDENTIAL DR STE 510
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8207
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-396-8971
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9046103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist