Provider Demographics
NPI:1265964993
Name:BERTTUCCI, ALEXANDRA LEIGH (MAC, LPC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LEIGH
Last Name:BERTTUCCI
Suffix:
Gender:F
Credentials:MAC, LPC
Other - Prefix:
Other - First Name:ALLY
Other - Middle Name:LEIGH
Other - Last Name:BERTTUCCI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAC, LPC
Mailing Address - Street 1:2811 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1006
Mailing Address - Country:US
Mailing Address - Phone:314-379-9905
Mailing Address - Fax:
Practice Address - Street 1:2811 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1006
Practice Address - Country:US
Practice Address - Phone:314-379-9905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional