Provider Demographics
NPI:1235766338
Name:BERTELLI, PETER A (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:BERTELLI
Suffix:
Gender:
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1081
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-4081
Mailing Address - Country:US
Mailing Address - Phone:803-809-3184
Mailing Address - Fax:803-615-4662
Practice Address - Street 1:244 LATITUDE LN STE 104
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8125
Practice Address - Country:US
Practice Address - Phone:803-809-3184
Practice Address - Fax:803-615-4662
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61656954363LP0808X
MARN2317837363LP0808X
SC28167363LP0808X
NC5019724363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health