Healthcare Provider Details

I. General information

NPI: 1629794227
Provider Name (Legal Business Name): LAURISSA BERTSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 PRAIRIE LAKES BLVD N STE 202
NOBLESVILLE IN
46060-4370
US

IV. Provider business mailing address

314 E NORTH ST
WESTFIELD IN
46074-9486
US

V. Phone/Fax

Practice location:
  • Phone: 317-569-5433
  • Fax:
Mailing address:
  • Phone: 765-977-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34008896A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: