Provider Demographics
NPI:1568814044
Name:DIBERNARDO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DIBERNARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 SAINT CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3410
Mailing Address - Country:US
Mailing Address - Phone:425-791-2550
Mailing Address - Fax:
Practice Address - Street 1:801 RUE SAINT FRANCOIS ST
Practice Address - Street 2:STE D
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-4948
Practice Address - Country:US
Practice Address - Phone:314-219-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160181371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical