Provider Demographics
NPI:1245585058
Name:CONRAD BUGARIN BERNISTO
Entity Type:Organization
Organization Name:CONRAD BUGARIN BERNISTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNISTO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:808-282-1907
Mailing Address - Street 1:4348 WAIALAE AVE # 656
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5767
Mailing Address - Country:US
Mailing Address - Phone:808-282-1907
Mailing Address - Fax:
Practice Address - Street 1:94-141 MAKOA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4728
Practice Address - Country:US
Practice Address - Phone:808-282-1907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty