Provider Demographics
NPI:1487674917
Name:BERTOULIN, MELISSA RENEE (MSW LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RENEE
Last Name:BERTOULIN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:RENEE
Other - Last Name:FAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LICSW
Mailing Address - Street 1:PO BOX 3300
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03105-3300
Mailing Address - Country:US
Mailing Address - Phone:603-645-5977
Mailing Address - Fax:603-645-5980
Practice Address - Street 1:138 WEBSTER STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104
Practice Address - Country:US
Practice Address - Phone:603-645-5977
Practice Address - Fax:603-645-5980
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30424174Medicaid
NH30424174Medicaid