Provider Demographics
NPI:1578187621
Name:BERNARD, KRISTEN TILLERY (COTA)
Entity Type:Individual
Prefix:PROF
First Name:KRISTEN
Middle Name:TILLERY
Last Name:BERNARD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGH DUNE LOOP
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN SHORES
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3706
Mailing Address - Country:US
Mailing Address - Phone:252-982-6087
Mailing Address - Fax:
Practice Address - Street 1:3907 CARATOKE HWY
Practice Address - Street 2:
Practice Address - City:BARCO
Practice Address - State:NC
Practice Address - Zip Code:27917-9500
Practice Address - Country:US
Practice Address - Phone:252-457-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3151224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3151OtherCOTA