Provider Demographics
NPI:1407047285
Name:DEBERNARDO, GINA MARIE
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DEBERNARDO
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 1:713 PINE FOREST TRL E
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4872
Mailing Address - Country:US
Mailing Address - Phone:386-405-0588
Mailing Address - Fax:
Practice Address - Street 1:713 PINE FOREST TRL E
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4872
Practice Address - Country:US
Practice Address - Phone:386-405-0588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30379225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist