Healthcare Provider Details

I. General information

NPI: 1750169470
Provider Name (Legal Business Name): MR. BERNARD TIMOTHY SEWELL III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 CAMELBACK RD APT 2
PLEASANT HILL CA
94523-1307
US

IV. Provider business mailing address

319 CAMELBACK RD APT 2
PLEASANT HILL CA
94523-1307
US

V. Phone/Fax

Practice location:
  • Phone: 214-310-6174
  • Fax:
Mailing address:
  • Phone: 214-310-6174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: