Provider Demographics
NPI:1144580515
Name:BERNHARDT BAINBRIDGE, DONNA B
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:B
Last Name:BERNHARDT BAINBRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:B
Other - Last Name:BERNHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3480 SALISH TRL
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-6501
Mailing Address - Country:US
Mailing Address - Phone:406-777-5861
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MONTANA
Practice Address - Street 2:SKAGGS BUILDING
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0001
Practice Address - Country:US
Practice Address - Phone:406-243-4006
Practice Address - Fax:406-243-4303
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-20
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT344981Medicaid
MT810489624OtherSTATE FUND
MT810489624OtherSTATE FUND