Provider Demographics
NPI:1134706500
Name:BERARDO, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BERARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HIGH ACRE DR
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-3900
Mailing Address - Country:US
Mailing Address - Phone:203-942-3384
Mailing Address - Fax:
Practice Address - Street 1:2095 HILLSIDE RD # U-1110
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-1110
Practice Address - Country:US
Practice Address - Phone:860-486-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23365146N00000X
390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program