Provider Demographics
NPI:1114471190
Name:BERNHARDT, DALLAS KARL
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:KARL
Last Name:BERNHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 PACKERS CT
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-3902
Mailing Address - Country:US
Mailing Address - Phone:608-330-1626
Mailing Address - Fax:
Practice Address - Street 1:1520 PACKERS CT
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3902
Practice Address - Country:US
Practice Address - Phone:608-330-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2327225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$Medicaid