Provider Demographics
NPI:1821539693
Name:BERNARDINI, ALYSIA SUSANN (NCSP)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:SUSANN
Last Name:BERNARDINI
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-4165
Mailing Address - Country:US
Mailing Address - Phone:618-973-8987
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4165
Practice Address - Country:US
Practice Address - Phone:618-973-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1999608103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool