MEDICARE: DR. NANCY BERNTHAL PHD

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	103T00000X	Psychologist	6301007895	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6301007895	OTHER	MI	LISCENSE NUMBER

General Provider Information

NPI Number	:	1851468839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NANCY BERNTHAL PHD

Provider Business Mailing Address
First Line	:	3448 E LAKE LANSING RD
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-1511
Country	:	US
Telephone Number	:	517-332-3870
Fax Number	:	517-332-9247

Provider Business Practice Location Address
First Line	:	3448 E LAKE LANSING RD
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-1511
Country	:	US
Telephone Number	:	517-332-3870
Fax Number	:	517-332-9247

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	02/11/2012

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