Provider Demographics
NPI:1558505214
Name:VIADO, BERNA AMISTOSO (PT)
Entity Type:Individual
Prefix:
First Name:BERNA
Middle Name:AMISTOSO
Last Name:VIADO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 KAISER DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4555
Mailing Address - Country:US
Mailing Address - Phone:410-750-9006
Mailing Address - Fax:
Practice Address - Street 1:3264 KAISER DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4555
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-26
Last Update Date:2009-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT871011225100000X
MI5501014363225100000X
NY030405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT871011OtherDC PT LICENSE
030405OtherNEW YORK PT LICENSE
5501014363OtherMI PT LICENSE