Provider Demographics
NPI:1861014938
Name:BERNARDONI, REGAN MOORE
Entity Type:Individual
Prefix:MS
First Name:REGAN
Middle Name:MOORE
Last Name:BERNARDONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 FRY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:LYNNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38472-5334
Mailing Address - Country:US
Mailing Address - Phone:912-508-1329
Mailing Address - Fax:
Practice Address - Street 1:2122 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4430
Practice Address - Country:US
Practice Address - Phone:931-490-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness