Provider Demographics
NPI:1578683926
Name:BERTAGNOLLI, ANDREW E (PH D)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:E
Last Name:BERTAGNOLLI
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 HICKEY BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2630
Mailing Address - Country:US
Mailing Address - Phone:650-985-7500
Mailing Address - Fax:650-985-7511
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2204
Practice Address - Country:US
Practice Address - Phone:650-985-7500
Practice Address - Fax:650-985-7511
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15734103T00000X
HI1638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00360060OtherRAILROAD MEDICARE
CAP00360060OtherRAILROAD MEDICARE
CA0PL157340Medicare PIN