Provider Demographics
NPI:1336407337
Name:BERNAIX, CARA LYNN
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:LYNN
Last Name:BERNAIX
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 1:2914 N RODGERS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-8846
Mailing Address - Country:US
Mailing Address - Phone:618-410-3391
Mailing Address - Fax:618-259-3334
Practice Address - Street 1:1373 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1767
Practice Address - Country:US
Practice Address - Phone:618-468-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002908225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant