Healthcare Provider Details

I. General information

NPI: 1093864159
Provider Name (Legal Business Name): MICHAEL DEBERNARDI PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CERRILLOS RD
SANTA FE NM
87505-3373
US

IV. Provider business mailing address

640 HERMIT FALLS DR SE
RIO RANCHO NM
87124-7285
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-0010
  • Fax: 505-438-6011
Mailing address:
  • Phone: 505-670-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number742
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: