Provider Demographics
NPI:1376055665
Name:BERTUCCI, MARK DOMINIC (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOMINIC
Last Name:BERTUCCI
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 WASHBURN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1929
Mailing Address - Country:US
Mailing Address - Phone:906-362-4078
Mailing Address - Fax:
Practice Address - Street 1:675 E NICOLLET BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6768
Practice Address - Country:US
Practice Address - Phone:952-993-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical