Provider Demographics
NPI:1790593820
Name:BERTUCCIO, LISA (NBC-HWC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BERTUCCIO
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10963-3118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 GRANGE RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:NY
Practice Address - Zip Code:10963-3118
Practice Address - Country:US
Practice Address - Phone:845-650-9253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach