Provider Demographics
NPI:1225160724
Name:BERTHIAUME, JEFFREY DENNIS (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DENNIS
Last Name:BERTHIAUME
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CALLIE CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-5900
Mailing Address - Country:US
Mailing Address - Phone:910-431-1828
Mailing Address - Fax:910-791-5615
Practice Address - Street 1:516 CALLIE CT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-5900
Practice Address - Country:US
Practice Address - Phone:910-431-1828
Practice Address - Fax:910-791-5615
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102027Medicaid