Healthcare Provider Details

I. General information

NPI: 1871693515
Provider Name (Legal Business Name): JACQUELINE BERTOLINI MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W GATES
ROMEO MI
48065
US

IV. Provider business mailing address

36975 UTICA ROAD SUITE 103
CLINTON TOWNSHIP MI
48036
US

V. Phone/Fax

Practice location:
  • Phone: 586-752-9696
  • Fax: 586-752-9157
Mailing address:
  • Phone: 586-226-3440
  • Fax: 586-226-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6401003255
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: