Provider Demographics
NPI:1932375029
Name:BERTELSEN, LORA J (PHD)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:J
Last Name:BERTELSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 STONE LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5679
Mailing Address - Country:US
Mailing Address - Phone:218-556-2858
Mailing Address - Fax:888-375-3627
Practice Address - Street 1:1868 STONE LAKE RD NW
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-556-2858
Practice Address - Fax:888-375-3627
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4416103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN713528Medicare PIN