Provider Demographics
NPI:1386251569
Name:BERTRAM, LORI ANN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:BERTRAM
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 1:9 PARK AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-3187
Mailing Address - Country:US
Mailing Address - Phone:781-738-8198
Mailing Address - Fax:
Practice Address - Street 1:9 PARK AVE APT 306
Practice Address - Street 2:
Practice Address - City:HULL
Practice Address - State:MA
Practice Address - Zip Code:02045-3187
Practice Address - Country:US
Practice Address - Phone:781-738-8198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10214311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical