Healthcare Provider Details

I. General information

NPI: 1508107962
Provider Name (Legal Business Name): ODALIS M. BERTO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N RAYMOND AVE STE 810
PASADENA CA
91103-4479
US

IV. Provider business mailing address

3408 BUENA VISTA AVE
GLENDALE CA
91208-1505
US

V. Phone/Fax

Practice location:
  • Phone: 818-726-4294
  • Fax:
Mailing address:
  • Phone: 818-726-4294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 19481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: