MEDICARE: MR. GARY PHILIP BERTUCCELLI 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	1041C0700X	Clinical Social Worker	LCSW24931	CA

General Provider Information

NPI Number	:	1750078259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY PHILIP BERTUCCELLI LCSW

Provider Business Mailing Address
First Line	:	1048 MONROE ST APT 219
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95050-4865
Country	:	US
Telephone Number	:	408-309-6251
Fax Number	:

Provider Business Practice Location Address
First Line	:	1048 MONROE ST APT 219
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95050-4865
Country	:	US
Telephone Number	:	408-309-6251
Fax Number	:

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

Provider Enumeration Date	:	04/24/2023
Last Update Date	:	04/24/2023

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