Provider Demographics
NPI:1013003441
Name:BERN, ELLIOT HARVEY (PHD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:HARVEY
Last Name:BERN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PENNSYLVANIA AVE
Mailing Address - Street 2:PO BOX 188
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1713
Mailing Address - Country:US
Mailing Address - Phone:570-491-4728
Mailing Address - Fax:
Practice Address - Street 1:1011 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336-1713
Practice Address - Country:US
Practice Address - Phone:570-491-4728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS2791L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical