Provider Demographics
NPI:1316504418
Name:BERNAL, CHRISTIAN
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:BERNAL
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 1:1056 WASS ST
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2854
Mailing Address - Country:US
Mailing Address - Phone:714-244-6791
Mailing Address - Fax:
Practice Address - Street 1:5762 BOLSA AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:714-292-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician