Provider Demographics
NPI:1245646504
Name:BERTIE, RICHARD (MS, LAT, ATC, PES)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BERTIE
Suffix:
Gender:M
Credentials:MS, LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 169
Mailing Address - Street 2:188 MAHANOY ST.
Mailing Address - City:NUREMBERG
Mailing Address - State:PA
Mailing Address - Zip Code:18241-0169
Mailing Address - Country:US
Mailing Address - Phone:570-951-9952
Mailing Address - Fax:
Practice Address - Street 1:117 EVERGREEN DR
Practice Address - Street 2:STOKES ATHLETIC CENTER, SAINT FRANCIS UNIVERSITY
Practice Address - City:LORETTO
Practice Address - State:PA
Practice Address - Zip Code:15940-9704
Practice Address - Country:US
Practice Address - Phone:570-951-9952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0057232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer