Healthcare Provider Details

I. General information

NPI: 1124835236
Provider Name (Legal Business Name): LARA BERNARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9514 CONSOLE DR
SAN ANTONIO TX
78229-2069
US

IV. Provider business mailing address

9514 CONSOLE DR
SAN ANTONIO TX
78229-2069
US

V. Phone/Fax

Practice location:
  • Phone: 210-448-9111
  • Fax: 210-308-9595
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number125227
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: