Provider Demographics
NPI:1386065696
Name:BERTHELOT, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:BERTHELOT
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 1:524 HIGHLAND ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-2120
Mailing Address - Country:US
Mailing Address - Phone:727-827-4778
Mailing Address - Fax:727-827-4779
Practice Address - Street 1:524 HIGHLAND ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-2120
Practice Address - Country:US
Practice Address - Phone:727-827-4778
Practice Address - Fax:727-827-4779
Is Sole Proprietor?:No
Enumeration Date:2014-01-05
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10104172V00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141913700Medicaid