Provider Demographics
NPI:1376161604
Name:EDELSTEIN, BERTRAM CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:CHARLES
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1632
Mailing Address - Country:US
Mailing Address - Phone:619-417-2821
Mailing Address - Fax:858-362-1414
Practice Address - Street 1:1705 OXFORD AVE
Practice Address - Street 2:
Practice Address - City:CARDIFF
Practice Address - State:CA
Practice Address - Zip Code:92007-1632
Practice Address - Country:US
Practice Address - Phone:619-417-2821
Practice Address - Fax:858-362-1414
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist