=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568714509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERNIE'S PLACE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2012
-----------------------------------------------------
Last Update Date | 10/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2635 E MONUMENT ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21205-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-438-6449
-----------------------------------------------------
Fax | 443-835-2168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3236 NORTHWAY DR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21234-7827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-438-6449
-----------------------------------------------------
Fax | 443-835-2168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | KIMBERLY BOSTIC
-----------------------------------------------------
Credential | BS, HUMAN SERVICE
-----------------------------------------------------
Telephone | 443-677-5720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------