Provider Demographics
NPI:1477890853
Name:BERT, VICKIE BACHUS (PHD)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:BACHUS
Last Name:BERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 MONTECITO AVE
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-5140
Mailing Address - Country:US
Mailing Address - Phone:818-590-2507
Mailing Address - Fax:805-241-5938
Practice Address - Street 1:2535 TOWNSGATE RD STE 209
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5976
Practice Address - Country:US
Practice Address - Phone:818-590-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-06
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11123103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist