MEDICARE: PAUL MATTHEW BERTOLINO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	SW17993	FL
2	1041C0700X	Clinical Social Worker	SW17993	FL

General Provider Information

NPI Number	:	1083152524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL MATTHEW BERTOLINO LCSW

Provider Business Mailing Address
First Line	:	974 SW WORCESTER LN
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2648
Country	:	US
Telephone Number	:	772-678-9040
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 NW CENTRAL PARK PLZ STE 107
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2482
Country	:	US
Telephone Number	:	772-678-9040
Fax Number	:	772-673-0790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2017
Last Update Date	:	04/21/2023

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