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General NPI Number Information
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NPI Number | 1467215590
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Entity Type | Individual
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Provider Name | BERTOLD FORLEMU
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Gender | Male
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Dates
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Enumeration Date | 02/01/2024
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Last Update Date | 02/01/2024
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Provider Practice Location Address
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Address Line | 606 E PRESS RD
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85140-5469
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Country | US
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Telephone | 480-295-5878
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Fax |
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Provider Business Mailing Address
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Address Line | 5760 E THETIS DR
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City | FLORENCE
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State | AZ
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Zip | 85132-5549
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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