MEDICARE: RAFAEL C BERTRAN LPC

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	101YP2500X	Professional Counselor	15637	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84479L	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1760494405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAFAEL C BERTRAN LPC

Provider Business Mailing Address
First Line	:	9563 CANTURA CRST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-1719
Country	:	US
Telephone Number	:	210-647-3814
Fax Number	:	210-647-3814

Provider Business Practice Location Address
First Line	:	9563 CANTURA CRST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-1719
Country	:	US
Telephone Number	:	210-647-3814
Fax Number	:	210-647-3814

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/08/2007

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