MEDICARE: DR. KEITH BERNARDO PH.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	35134	TX

General Provider Information

NPI Number	:	1982953931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH BERNARDO PH.D.

Provider Business Mailing Address
First Line	:	8333 DOUGLAS AVE
Second Line	:	SUITE 1240
City	:	DALLAS
State	:	TX
Zip	:	75225-5845
Country	:	US
Telephone Number	:	214-361-2622
Fax Number	:	214-361-8649

Provider Business Practice Location Address
First Line	:	8333 DOUGLAS AVE
Second Line	:	SUITE 1240
City	:	DALLAS
State	:	TX
Zip	:	75225-5845
Country	:	US
Telephone Number	:	214-361-2622
Fax Number	:	214-361-8649

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

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	03/19/2013

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