Provider Demographics
NPI:1134242431
Name:BERTOLUCCI, MICHAEL LEWIS (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEWIS
Last Name:BERTOLUCCI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 CRISLER WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-1501
Mailing Address - Country:US
Mailing Address - Phone:323-650-8381
Mailing Address - Fax:
Practice Address - Street 1:1744 CRISLER WAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-1501
Practice Address - Country:US
Practice Address - Phone:323-650-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22064106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist