Provider Demographics
NPI:1689979718
Name:HARVEY, BERTILDA ISABEL
Entity Type:Individual
Prefix:MS
First Name:BERTILDA
Middle Name:ISABEL
Last Name:HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BERTILDA
Other - Middle Name:ISABEL
Other - Last Name:HARVEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:913 LEE ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-4310
Mailing Address - Country:US
Mailing Address - Phone:352-874-5646
Mailing Address - Fax:352-326-8177
Practice Address - Street 1:913 LEE ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4310
Practice Address - Country:US
Practice Address - Phone:352-874-5646
Practice Address - Fax:352-326-8177
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
676209368OtherMEDICAID WAIVER - CONSUMER DIRECTED CARE PLUS
FL676209396OtherMEDICAID WAIVER - HOME AND COMMUNITY BASED SERVICES.
676209398OtherMEDICAID WAIVER - FAMILY SUPPORTED LIVING WAIVER