MEDICARE: TERESA ANN BERTONCIN LMFT, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0138711	NM
2	106H00000X	Marriage & Family Therapist	T-0136651	NM
3	106H00000X	Marriage & Family Therapist	484	HI
4	106H00000X	Marriage & Family Therapist	120966	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255582367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA ANN BERTONCIN LMFT, LPCC

Provider Business Mailing Address
First Line	:	1842 20TH ST
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-3913
Country	:	US
Telephone Number	:	808-345-4333
Fax Number	:

Provider Business Practice Location Address
First Line	:	1842 20TH ST
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-3913
Country	:	US
Telephone Number	:	808-345-4333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	03/27/2023

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