Provider Demographics
NPI:1194156190
Name:BERN, SALLY
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:
Last Name:BERN
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 1:700 HUNTINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-8902
Mailing Address - Country:US
Mailing Address - Phone:360-501-2910
Mailing Address - Fax:
Practice Address - Street 1:700 HUNTINGTON AVE S
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-8902
Practice Address - Country:US
Practice Address - Phone:360-501-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60405634235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist