Provider Demographics
NPI:1629597000
Name:BERTUBIN, DANA ROCHELLE
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:ROCHELLE
Last Name:BERTUBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 VANMARK WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 MAPLEWOOD COMMONS DR
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-1000
Practice Address - Country:US
Practice Address - Phone:314-646-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2017-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009001308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist