Healthcare Provider Details

I. General information

NPI: 1306201751
Provider Name (Legal Business Name): LAURELL BERTINO LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 08/03/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 W SAINT CHARLES ST
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

PO BOX 2218
MURPHYS CA
95247-2218
US

V. Phone/Fax

Practice location:
  • Phone: 209-286-9945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: