MEDICARE: DR. KATHARINE BERTOLET PSY.D.

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	103TC0700X	Clinical Psychologist	PS-005871-L	PA

General Provider Information

NPI Number	:	1508914664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHARINE BERTOLET PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 27071
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-0071
Country	:	US
Telephone Number	:	215-247-5440
Fax Number	:	215-887-0719

Provider Business Practice Location Address
First Line	:	7600 STENTON AVE
Second Line	:	SUITE ONE-I
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3231
Country	:	US
Telephone Number	:	215-247-5440
Fax Number	:	215-887-0719

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/09/2007

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