Provider Demographics
NPI:1316992100
Name:MCDONNELL, BERNADETTE CATHERINE (PT, LCCE)
Entity type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:CATHERINE
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:PT, LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 HAVERFORD AVE
Mailing Address - Street 2:#7
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-4378
Mailing Address - Country:US
Mailing Address - Phone:310-459-4286
Mailing Address - Fax:
Practice Address - Street 1:840 HAVERFORD AVE
Practice Address - Street 2:#7
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-4378
Practice Address - Country:US
Practice Address - Phone:323-464-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT9797AMedicaid