Basic Information
| Provider Information | |||||||||
| NPI: | 1558431569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNHARDT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.S., LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 HAMPSTEAD HEATH LN | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275024357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192676602 | ||||||||
| FaxNumber: | 9196831790 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S MANGUM ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277013904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196831607 | ||||||||
| FaxNumber: | 9196831790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 962 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6111915 | 05 | NC | MEDICAID |