Provider Demographics
NPI:1295784700
Name:BERTERA, JOHN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BERTERA
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 1:460 WEST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3653
Mailing Address - Country:US
Mailing Address - Phone:508-790-3375
Mailing Address - Fax:508-790-3304
Practice Address - Street 1:460 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3653
Practice Address - Country:US
Practice Address - Phone:508-790-3375
Practice Address - Fax:508-790-3304
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5017103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W51087Medicare ID - Type Unspecified