Provider Demographics
NPI:1407018591
Name:BRYAN DEBERNARDO, MARILYN (LMHC, CASAC-G)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BRYAN DEBERNARDO
Suffix:
Gender:F
Credentials:LMHC, CASAC-G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 DUNSBACH PD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065
Mailing Address - Country:US
Mailing Address - Phone:518-847-7803
Mailing Address - Fax:518-280-5049
Practice Address - Street 1:4 TECHNICAL PARK
Practice Address - Street 2:SUITE #3, #6
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-847-7803
Practice Address - Fax:518-280-5049
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11051101YA0400X, 261QR0405X
NY002250-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid