Healthcare Provider Details

I. General information

NPI: 1356462394
Provider Name (Legal Business Name): NICHOLE BERNHARD O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ROUND VALLEY DR
PARK CITY UT
84060-7552
US

IV. Provider business mailing address

PO BOX 511258
LOS ANGELES CA
90051-7813
US

V. Phone/Fax

Practice location:
  • Phone: 435-658-7359
  • Fax:
Mailing address:
  • Phone: 801-584-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number321294-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: