Healthcare Provider Details

I. General information

NPI: 1780590182
Provider Name (Legal Business Name): CALISHA MARIE BERTRAM LMHC-D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 BROWNCROFT BOULEVARD SUITE 204B
PENFIELD NY
14526
US

IV. Provider business mailing address

2507 BROWNCROFT BOULEVARD SUITE 204 B
PENFIELD NY
14526
US

V. Phone/Fax

Practice location:
  • Phone: 585-348-8222
  • Fax:
Mailing address:
  • Phone: 583-348-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: