Provider Demographics
NPI:1689737181
Name:BERNARD, SAM DAVID (MA, PHD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:DAVID
Last Name:BERNARD
Suffix:
Gender:M
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BRENTLY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4454
Mailing Address - Country:US
Mailing Address - Phone:423-322-3297
Mailing Address - Fax:423-370-0018
Practice Address - Street 1:6148 LEE HWY
Practice Address - Street 2:SUITE 208
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2994
Practice Address - Country:US
Practice Address - Phone:423-322-3297
Practice Address - Fax:423-370-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
27004 NBCC101YM0800X
TNPE1378103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health