Provider Demographics
NPI:1073660379
Name:MIMNAUGH, BERNS ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERNS
Middle Name:ROBERT
Last Name:MIMNAUGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:BERNS
Other - Middle Name:ROBERT
Other - Last Name:MIMNAUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:405 PITTSFIELD RD
Mailing Address - Street 2:UNIT I-1
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2901
Mailing Address - Country:US
Mailing Address - Phone:413-236-5700
Mailing Address - Fax:413-236-5701
Practice Address - Street 1:405 PITTSFIELD RD
Practice Address - Street 2:UNIT I-1
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2901
Practice Address - Country:US
Practice Address - Phone:413-236-5700
Practice Address - Fax:413-236-5701
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY62036Medicare ID - Type Unspecified