Provider Demographics
NPI:1689958282
Name:BERNBECK, NICHOLAS A (LLPC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:BERNBECK
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18090 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-6251
Mailing Address - Country:US
Mailing Address - Phone:313-590-6339
Mailing Address - Fax:
Practice Address - Street 1:18090 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-6251
Practice Address - Country:US
Practice Address - Phone:313-590-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-01
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012641101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910776OtherBC TRUST
MIXX19153OtherHEALTHPLUS
MI750910776OtherBCBS CHRYSLER
MI032919OtherMIDWEST HEALTH PLAN
MI750910776OtherBCMI
MI00260F7OtherHAP
MI750910776OtherBC OOS
MI750910776OtherBCBS FED