Basic Information
| Provider Information | |||||||||
| NPI: | 1114367687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTOLDO | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LUCERO | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14135 MAIN ST. HESPERIA SUITE 301 | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662053595 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3125 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW68317 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.