Provider Demographics
NPI:1922339712
Name:BERNAL, MARTHA (PTA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BERNAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 81ST ST APT 4L
Mailing Address - Street 2:
Mailing Address - City:JACKSON HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5030
Mailing Address - Country:US
Mailing Address - Phone:718-440-9439
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVE
Practice Address - Street 2:MLK BLDG
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005749-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant