Provider Demographics
NPI:1013629401
Name:DAVIS, BERNADETTE
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:DAVIS
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 1:1426 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-4059
Mailing Address - Country:US
Mailing Address - Phone:201-600-8954
Mailing Address - Fax:
Practice Address - Street 1:700 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5907
Practice Address - Country:US
Practice Address - Phone:732-367-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05507500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker