Provider Demographics
NPI:1053610600
Name:BERNARD, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BERNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVALE
Mailing Address - State:ME
Mailing Address - Zip Code:04083-1409
Mailing Address - Country:US
Mailing Address - Phone:207-324-1500
Mailing Address - Fax:207-490-5263
Practice Address - Street 1:474 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083-1409
Practice Address - Country:US
Practice Address - Phone:207-324-1500
Practice Address - Fax:207-490-5263
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC97331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical