MEDICARE: DR. BERNARDINE SUPPA PSY D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PS008862L	PA
2	103T00000X	Psychologist	PS008862L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497809438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNARDINE SUPPA PSY D

Provider Business Mailing Address
First Line	:	38 NORTH ST
Second Line	:
City	:	COURTDALE
State	:	PA
Zip	:	18704-1713
Country	:	US
Telephone Number	:	570-288-2430
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 LUZERNE AVE
Second Line	:
City	:	WEST PITTSTON
State	:	PA
Zip	:	18643-2817
Country	:	US
Telephone Number	:	570-961-3361
Fax Number	:	570-961-3364

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	11/15/2023

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