Provider Demographics
NPI:1134350366
Name:BERNHARDT, NICOLETTE MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICOLETTE
Middle Name:MARIE
Last Name:BERNHARDT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:MARIE
Other - Last Name:BALKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:701 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1612
Mailing Address - Country:US
Mailing Address - Phone:708-681-3200
Mailing Address - Fax:708-538-5661
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-681-3200
Practice Address - Fax:708-538-5661
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.003966101YM0800X
IL071.008846103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health