Provider Demographics
NPI:1255582367
Name:BERTONCIN, TERESA ANN (LMFT, LPCC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:BERTONCIN
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3913
Mailing Address - Country:US
Mailing Address - Phone:808-345-4333
Mailing Address - Fax:
Practice Address - Street 1:1842 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3913
Practice Address - Country:US
Practice Address - Phone:808-345-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0138711101YM0800X
NMT-0136651106H00000X
HI484106H00000X
CA120966106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39654753Medicaid