Provider Demographics
NPI:1992782247
Name:BERNARD, BRYAN A (PHD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:BERNARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:STE 755
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-563-2900
Mailing Address - Fax:312-563-2024
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:STE 755
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-563-2900
Practice Address - Fax:312-563-2024
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071004071OtherLICENSE
IL071004071OtherLICENSE
K03056Medicare ID - Type Unspecified