Provider Demographics
NPI:1639159338
Name:BERNTSON, MARY LYNN (OTRL CHT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:BERNTSON
Suffix:
Gender:F
Credentials:OTRL CHT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:FLORENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:1451 44TH AVE S
Mailing Address - Street 2:UNIT 120D
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-732-2947
Mailing Address - Fax:701-732-2945
Practice Address - Street 1:1451 44TH AVE S
Practice Address - Street 2:UNIT 120D
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-732-2947
Practice Address - Fax:701-732-2945
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND25225X00000X
MN100966225X00000X
AA522599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201942600OtherMEDICAL ASSISTANCE
24561OtherNORIDIAN MUTUAL
ND54901Medicaid
24561OtherBCBS ND
24780OtherDEMERS LOCATION
1042277OtherPREFERRED ONE
MN341M0BEOtherBC/BS
64-05705OtherMEDICA
HP62219OtherHEALTH PARTNERS
2605838OtherUNITED HEALTH CARE
MN341M0BEOtherBC/BS
24561OtherNORIDIAN MUTUAL
24561Medicare ID - Type Unspecified