Provider Demographics
NPI:1811006448
Name:BERTEAU, ANNE WAGUESPACK (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:WAGUESPACK
Last Name:BERTEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6839 YORKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-6700
Mailing Address - Country:US
Mailing Address - Phone:850-939-9124
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY
Practice Address - Street 2:SUITE 602
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1988
Practice Address - Country:US
Practice Address - Phone:850-244-0101
Practice Address - Fax:850-243-9795
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW34841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z6174Medicare ID - Type Unspecified