MEDICARE: MARY BETH BERTOTTI MA LMHC LMFT

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	39000544A	IN
2	106H00000X	Marriage & Family Therapist	35000547A	IN

General Provider Information

NPI Number	:	1578512943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BETH BERTOTTI MA LMHC LMFT

Provider Business Mailing Address
First Line	:	1040 SIERRA DR
Second Line	:	SUITE 400
City	:	GREENWOOD
State	:	IN
Zip	:	46143-7240
Country	:	US
Telephone Number	:	317-528-4886
Fax Number	:	317-859-8239

Provider Business Practice Location Address
First Line	:	610 E SOUTHPORT RD
Second Line	:	SUITE 100
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-8590
Country	:	US
Telephone Number	:	317-783-8383
Fax Number	:	317-782-6929

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/14/2015

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