Provider Demographics
NPI:1053520270
Name:BERNARD, MELISSA (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BERNARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 TEMPLAR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-3932
Mailing Address - Country:US
Mailing Address - Phone:419-461-0707
Mailing Address - Fax:419-474-5165
Practice Address - Street 1:3949 SUNFOREST CT
Practice Address - Street 2:SUITE 101
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4473
Practice Address - Country:US
Practice Address - Phone:419-474-3399
Practice Address - Fax:419-474-5165
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT9344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325590OtherANTHEM
OH2208864Medicaid
OH2208864Medicaid