Provider Demographics
NPI:1629794227
Name:BERTSCH, LAURISSA
Entity Type:Individual
Prefix:
First Name:LAURISSA
Middle Name:
Last Name:BERTSCH
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 1:314 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9486
Mailing Address - Country:US
Mailing Address - Phone:765-977-0083
Mailing Address - Fax:
Practice Address - Street 1:14540 PRAIRIE LAKES BLVD N STE 202
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4370
Practice Address - Country:US
Practice Address - Phone:317-569-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008896A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical