Provider Demographics
NPI:1326312323
Name:GINO BERTUCCI, LCSW LLC
Entity Type:Organization
Organization Name:GINO BERTUCCI, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GINO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:225-938-9971
Mailing Address - Street 1:PO BOX 2731
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-2731
Mailing Address - Country:US
Mailing Address - Phone:225-938-9971
Mailing Address - Fax:225-635-6907
Practice Address - Street 1:7341 JEFFERSON HWY
Practice Address - Street 2:STE E
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8203
Practice Address - Country:US
Practice Address - Phone:225-938-9971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1568638260OtherINDIVIDUAL NPI