Provider Demographics
NPI:1083152524
Name:BERTOLINO, PAUL MATTHEW (LCSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MATTHEW
Last Name:BERTOLINO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 SW WORCESTER LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2648
Mailing Address - Country:US
Mailing Address - Phone:772-678-9040
Mailing Address - Fax:
Practice Address - Street 1:145 NW CENTRAL PARK PLZ STE 107
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2482
Practice Address - Country:US
Practice Address - Phone:772-678-9040
Practice Address - Fax:772-673-0790
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW17993104100000X, 1041C0700X
FLRBT-15-06456106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical