Provider Demographics
NPI:1407408594
Name:BERNSTEIN, BROOKS
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:
Last Name:BERNSTEIN
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 1:10901 BURNT MILL RD APT 306
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2846
Mailing Address - Country:US
Mailing Address - Phone:904-699-8335
Mailing Address - Fax:
Practice Address - Street 1:201 SIMONE WAY
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7750
Practice Address - Country:US
Practice Address - Phone:904-829-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 222Q00000X
FLRBT-19-92010106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty