Healthcare Provider Details

I. General information

NPI: 1407848864
Provider Name (Legal Business Name): BARRY LEE BERTOLETTE N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 NORTH MORGAN STREET
SHELBY NC
28150-4439
US

IV. Provider business mailing address

PO BOX 1418
SHELBY NC
28151-1418
US

V. Phone/Fax

Practice location:
  • Phone: 704-480-1882
  • Fax: 704-480-1832
Mailing address:
  • Phone: 704-480-1882
  • Fax: 704-480-1832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201451
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number201451
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number201451
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: