Provider Demographics
NPI:1336388198
Name:DEBERNARDI, AMY SUSAN (PSYD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUSAN
Last Name:DEBERNARDI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 HERMIT FALLS DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-7285
Mailing Address - Country:US
Mailing Address - Phone:505-670-2313
Mailing Address - Fax:
Practice Address - Street 1:22 ST. ANTHONY DRIVE
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327
Practice Address - Country:US
Practice Address - Phone:505-782-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM755103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N4239Medicaid