Healthcare Provider Details

I. General information

NPI: 1790593820
Provider Name (Legal Business Name): LISA BERTUCCIO NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 GRANGE RD
OTISVILLE NY
10963-3118
US

IV. Provider business mailing address

3 GRANGE RD
OTISVILLE NY
10963-3118
US

V. Phone/Fax

Practice location:
  • Phone: 845-650-9253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: