Healthcare Provider Details

I. General information

NPI: 1225283492
Provider Name (Legal Business Name): DONALD LEE BERNOVICH II PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST SUITE 100
BLOOMINGTON MN
55420-1400
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 952-854-5034
  • Fax: 952-854-5363
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5949
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: