Provider Demographics
NPI:1750046504
Name:BERTOLDO, ALICE DEBBIE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:DEBBIE
Last Name:BERTOLDO
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 1:1000 JEFFERSON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1724
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:5635 N SCOTTSDALE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-5937
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:617-807-0958
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional