Provider Demographics
NPI:1588210819
Name:BERTINO, JOHANNA B (RD, LD, CEDRD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:B
Last Name:BERTINO
Suffix:
Gender:F
Credentials:RD, LD, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MILLER ST
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1929
Mailing Address - Country:US
Mailing Address - Phone:859-539-3999
Mailing Address - Fax:
Practice Address - Street 1:4 PARKWAY COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-5213
Practice Address - Country:US
Practice Address - Phone:864-334-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC879133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty