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General NPI Number Information
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NPI Number | 1780308197
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Entity Type | Individual
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Provider Name | THEODORE JOSEPH BEMENDERFER
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Gender | Male
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Dates
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Enumeration Date | 09/29/2022
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 1145 STURGIS ROAD
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City | TWENTYNINE PALMS
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State | CA
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Zip | 92278
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Country | US
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Telephone | 317-752-3134
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Fax |
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Provider Business Mailing Address
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Address Line | 3407B DALY ST
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City | TWENTYNINE PALMS
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State | CA
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Zip | 92277-9468
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20043728A
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License Number State | IN
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