MEDICARE: PETER A. BERTELLI MSN, APRN, PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61656954	WA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN2317837	MA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	28167	SC
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5019724	NC

General Provider Information

NPI Number	:	1235766338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER A. BERTELLI MSN, APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 1081
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-4081
Country	:	US
Telephone Number	:	803-809-3184
Fax Number	:	803-615-4662

Provider Business Practice Location Address
First Line	:	244 LATITUDE LN STE 104
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-8125
Country	:	US
Telephone Number	:	803-809-3184
Fax Number	:	803-615-4662

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

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	02/19/2025

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