Provider Demographics
NPI:1164923686
Name:BERNAL, SELINA RENEE
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:RENEE
Last Name:BERNAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RANCHO VISTA PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4789
Mailing Address - Country:US
Mailing Address - Phone:909-706-0097
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:225 NEWMAN AVE
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:RI
Practice Address - Zip Code:02916-1218
Practice Address - Country:US
Practice Address - Phone:401-270-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-41550103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst