Provider Demographics
NPI:1184687667
Name:BERNHARDT, MARY WOLF (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WOLF
Last Name:BERNHARDT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SE FEDERAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4556
Mailing Address - Country:US
Mailing Address - Phone:772-678-6704
Mailing Address - Fax:772-888-1885
Practice Address - Street 1:2400 SE FEDERAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:726-786-7047
Practice Address - Fax:772-221-9969
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA888472112AMedicaid