Healthcare Provider Details

I. General information

NPI: 1164768065
Provider Name (Legal Business Name): NICHOLAS RUBEN DEBERNARDI PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 BALDWIN ST
JENISON MI
49428-8901
US

IV. Provider business mailing address

1836 BALDWIN ST
JENISON MI
49428-8901
US

V. Phone/Fax

Practice location:
  • Phone: 616-457-0016
  • Fax: 616-457-1950
Mailing address:
  • Phone: 616-457-0016
  • Fax: 616-457-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: