Healthcare Provider Details

I. General information

NPI: 1225663271
Provider Name (Legal Business Name): FANI F BERTOS MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 RIVER AVE STE 201
LAKEWOOD NJ
08701-5675
US

IV. Provider business mailing address

321 NORTH AVE E UNIT 125
CRANFORD NJ
07016-2468
US

V. Phone/Fax

Practice location:
  • Phone: 732-833-3723
  • Fax: 888-247-4390
Mailing address:
  • Phone: 609-471-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS01010600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: