Provider Demographics
NPI:1760468375
Name:BERNAL, KELLY D (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:BERNAL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11669 BOHR RD
Mailing Address - Street 2:
Mailing Address - City:MINERAL POINT
Mailing Address - State:MO
Mailing Address - Zip Code:63660-9206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 E HIGH ST
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1900
Practice Address - Country:US
Practice Address - Phone:573-436-1716
Practice Address - Fax:573-436-1515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004272101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor