=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356874515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE BERNARDI DPT, MAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2017
-----------------------------------------------------
Last Update Date | 01/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3021 FALLING WATERS BLVD STE B
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-6745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-356-2895
-----------------------------------------------------
Fax | 847-356-2919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 412031
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-7594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 191-429-4405
-----------------------------------------------------
Fax | 631-760-8306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070025323
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------