Healthcare Provider Details

I. General information

NPI: 1538731039
Provider Name (Legal Business Name): ALEXANDRA BERNAL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA REVELES PHD

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 NW SAMARITAN DR STE 215
CORVALLIS OR
97330-3893
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3394
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3394
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3394
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: