Provider Demographics
NPI:1306258579
Name:BERNARD, MAUREEN (PTA)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:BERNARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 B SAULS STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560
Mailing Address - Country:US
Mailing Address - Phone:843-374-0185
Mailing Address - Fax:843-374-0189
Practice Address - Street 1:3481 LADSON RD
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4300
Practice Address - Country:US
Practice Address - Phone:843-900-0745
Practice Address - Fax:866-396-4079
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2719225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2719OtherLICENSE NUMBER