Provider Demographics
NPI:1396244273
Name:MONDESTIN, BERTHANIE
Entity type:Individual
Prefix:
First Name:BERTHANIE
Middle Name:
Last Name:MONDESTIN
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 1:6148 WILLOUGHBY CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-9308
Mailing Address - Country:US
Mailing Address - Phone:561-843-4821
Mailing Address - Fax:
Practice Address - Street 1:6148 WILLOUGHBY CIR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-9308
Practice Address - Country:US
Practice Address - Phone:561-843-4821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician