Healthcare Provider Details

I. General information

NPI: 1558198226
Provider Name (Legal Business Name): ROBERT A BERTOLINO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CREVE COEUR AVE
MANCHESTER MO
63011-4037
US

IV. Provider business mailing address

713 CRANBROOK DR
KIRKWOOD MO
63122-3033
US

V. Phone/Fax

Practice location:
  • Phone: 314-852-7274
  • Fax:
Mailing address:
  • Phone: 314-852-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2447
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number300097
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: