=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235766338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER A. BERTELLI MSN, APRN, PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2020
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 244 LATITUDE LN STE 104
-----------------------------------------------------
City | LAKE WYLIE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29710-8125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-809-3184
-----------------------------------------------------
Fax | 803-615-4662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1081
-----------------------------------------------------
City | CLOVER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29710-4081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-809-3184
-----------------------------------------------------
Fax | 803-615-4662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP61656954
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN2317837
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 28167
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 5019724
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------