Provider Demographics
NPI:1245075472
Name:BERTULIS, KASSONDRA (PSYD)
Entity type:Individual
Prefix:DR
First Name:KASSONDRA
Middle Name:
Last Name:BERTULIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WATER ST APT 306
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3026
Mailing Address - Country:US
Mailing Address - Phone:860-378-5595
Mailing Address - Fax:
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7007
Practice Address - Country:US
Practice Address - Phone:860-378-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0006447103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist