Provider Demographics
NPI: | 1508914664 |
---|---|
Name: | BERTOLET, KATHARINE (PSYD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KATHARINE |
Middle Name: | |
Last Name: | BERTOLET |
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: | PO BOX 27071 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19118-0071 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 215-247-5440 |
Mailing Address - Fax: | 215-887-0719 |
Practice Address - Street 1: | 7600 STENTON AVE |
Practice Address - Street 2: | SUITE ONE-I |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19118-3231 |
Practice Address - Country: | US |
Practice Address - Phone: | 215-247-5440 |
Practice Address - Fax: | 215-887-0719 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-01-08 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | PS-005871-L | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 68602512 | Medicare UPIN | |
PA | 59686 | Medicare UPIN | |
PA | 650339 | Medicare UPIN | |
PA | 5673044 | Medicare UPIN | |
PA | 0481452000 | Medicare UPIN | |
PA | 279512 | Medicare UPIN |