Provider Demographics
NPI:1699845693
Name:PIERSON, BERNADETTE MARIE (OT)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:MARIE
Last Name:PIERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CHRISTYNE
Other - Middle Name:ANNETTE
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 E ELM AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3258
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:125 E ELM AVE
Practice Address - Street 2:STE 103
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3258
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825333OtherAHCCCS NUMBER