Provider Demographics
NPI:1457097131
Name:BERT, STEPHANIE (LISAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BERT
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 W FIRETHORN ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-4044
Mailing Address - Country:US
Mailing Address - Phone:520-261-0818
Mailing Address - Fax:
Practice Address - Street 1:4249 W INA RD STE 105
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2254
Practice Address - Country:US
Practice Address - Phone:520-261-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-155253103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty