Provider Demographics
NPI:1306468681
Name:BERTOLDI, KRYSTINA
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:
Last Name:BERTOLDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 EXECUTIVE PARK BLVD STE 4525
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-3326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:334 N 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4015
Practice Address - Country:US
Practice Address - Phone:669-250-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC10079101YM0800X
CAAMFT127233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health