Provider Demographics
NPI:1124808365
Name:BERNAUER, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BERNAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 SHINING WATER DR APT 301
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-6940
Mailing Address - Country:US
Mailing Address - Phone:502-689-6300
Mailing Address - Fax:
Practice Address - Street 1:2604 SHINING WATER DR APT 301
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6940
Practice Address - Country:US
Practice Address - Phone:502-689-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287692101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health