Provider Demographics
NPI:1184619629
Name:BERNAL, GUILLERMO A (PHD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:A
Last Name:BERNAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5228
Mailing Address - Country:US
Mailing Address - Phone:419-874-0274
Mailing Address - Fax:419-874-9960
Practice Address - Street 1:975 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5228
Practice Address - Country:US
Practice Address - Phone:419-874-0274
Practice Address - Fax:419-874-9960
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2917103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0455510Medicaid
R73136Medicare UPIN
OH0455510Medicaid