Provider Demographics
NPI:1497809438
Name:SUPPA, BERNARDINE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:BERNARDINE
Middle Name:
Last Name:SUPPA
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:MRS
Other - First Name:BERNARDINE
Other - Middle Name:
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:38 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:COURTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-1713
Mailing Address - Country:US
Mailing Address - Phone:570-288-2430
Mailing Address - Fax:
Practice Address - Street 1:16 LUZERNE AVE
Practice Address - Street 2:
Practice Address - City:WEST PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18643-2817
Practice Address - Country:US
Practice Address - Phone:570-961-3361
Practice Address - Fax:570-961-3364
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008862L103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017502200004Medicaid