Provider Demographics
NPI:1598109647
Name:BERNARD, AMENIAH V (CADC)
Entity type:Individual
Prefix:
First Name:AMENIAH
Middle Name:V
Last Name:BERNARD
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3310
Mailing Address - Country:US
Mailing Address - Phone:618-530-8822
Mailing Address - Fax:618-682-6182
Practice Address - Street 1:517 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3310
Practice Address - Country:US
Practice Address - Phone:618-530-8822
Practice Address - Fax:618-682-6182
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29861101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)