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NPI Code Detail

MEDICARE: DR. MARK DOMINIC BERTUCCI PSYD, LP

MEDICARE: DR. MARK DOMINIC BERTUCCI PSYD, LP
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
1103TC0700XClinical PsychologistLP6174MN

General Provider Information

NPI Number : 1376055665
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARK DOMINIC BERTUCCI PSYD, LP
Provider Business Mailing Address
First Line : 6929 WASHBURN AVE S
Second Line :
City : RICHFIELD
State : MN
Zip : 55423-1929
Country : US
Telephone Number : 906-362-4078
Fax Number :
Provider Business Practice Location Address
First Line : 675 E NICOLLET BLVD STE 250
Second Line :
City : BURNSVILLE
State : MN
Zip : 55337-6768
Country : US
Telephone Number : 952-993-3307
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2017
Last Update Date : 03/17/2018

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