Healthcare Provider Details

I. General information

NPI: 1033562699
Provider Name (Legal Business Name): CALEB ROBERT BERNHARDT PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N. PIEDRAS ST. ATTN EL PASO, TX, 79920-5001 WBAMC
APO AA
79920-5001
US

IV. Provider business mailing address

200 W BRIAR LN
ALLOUEZ WI
54301-1316
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-3305
  • Fax:
Mailing address:
  • Phone: 920-412-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6672-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: