Provider Demographics
NPI:1497883193
Name:BERTELSEN, KRISTINE ANN GRIMES (LMHC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:ANN GRIMES
Last Name:BERTELSEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1846 TRUMANSBURG RD.
Mailing Address - Street 2:P.O. BOX 157
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14854-0157
Mailing Address - Country:US
Mailing Address - Phone:607-387-5828
Mailing Address - Fax:
Practice Address - Street 1:415 N TIOGA ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4228
Practice Address - Country:US
Practice Address - Phone:607-272-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health