Provider Demographics
NPI:1316995095
Name:BERARDI, ANTHONY LOUIS (PHD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:LOUIS
Last Name:BERARDI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:300 S SAINT LOUIS BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3043
Mailing Address - Country:US
Mailing Address - Phone:574-232-1405
Mailing Address - Fax:574-232-0124
Practice Address - Street 1:300 S SAINT LOUIS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3043
Practice Address - Country:US
Practice Address - Phone:574-232-1405
Practice Address - Fax:574-232-0124
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN20010290A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100095590Medicaid
IN218200AMedicare PIN
IN100095590Medicaid