Provider Demographics
NPI:1184003238
Name:TEDESCO, BERNARD RICHARD (LPC)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:RICHARD
Last Name:TEDESCO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 GLENMERE DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6769
Mailing Address - Country:US
Mailing Address - Phone:508-965-4644
Mailing Address - Fax:436-668-2468
Practice Address - Street 1:608 16TH AVE N STE G
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3537
Practice Address - Country:US
Practice Address - Phone:843-501-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8185101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional