Basic Information
Provider Information | |||||||||
NPI: | 1700181773 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERNDT | ||||||||
FirstName: | CAROLL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D., J.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 278 NW LAURELLA LN | ||||||||
Address2: |   | ||||||||
City: | COLLEGE PLACE | ||||||||
State: | WA | ||||||||
PostalCode: | 993241265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703195564 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 77 WAINWRIGHT DR | ||||||||
Address2: | BUILDING 69 | ||||||||
City: | WALLA WALLA | ||||||||
State: | WA | ||||||||
PostalCode: | 993623975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095255200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/21/2011 | ||||||||
LastUpdateDate: | 01/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071-004131 | IL | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 3215 | CO | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.