Provider Demographics
NPI:1326897661
Name:BERTUCCI, MARISSA JANE (PC-A)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:JANE
Last Name:BERTUCCI
Suffix:
Gender:F
Credentials:PC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 SE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-7234
Mailing Address - Country:US
Mailing Address - Phone:925-726-8472
Mailing Address - Fax:
Practice Address - Street 1:15300 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-4839
Practice Address - Country:US
Practice Address - Phone:925-726-8472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health