Provider Demographics
NPI:1053345504
Name:BERTUCELLI, JEANNETTE STICCO (R-LCSW:ACSW)
Entity type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:STICCO
Last Name:BERTUCELLI
Suffix:
Gender:F
Credentials:R-LCSW:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PROFESSIONAL PLAZA 233 7TH ST.
Mailing Address - Street 2:2FL SUITE
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4147
Mailing Address - Country:US
Mailing Address - Phone:516-662-8258
Mailing Address - Fax:516-385-2913
Practice Address - Street 1:PROFESSIONAL PLAZA 233 7TH ST.
Practice Address - Street 2:2FL SUITE
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4147
Practice Address - Country:US
Practice Address - Phone:516-662-8258
Practice Address - Fax:516-385-2913
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0694351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300000572Medicare PIN
NY4740UBMedicare UPIN
NYA400015740Medicare PIN