Provider Demographics
NPI:1457129785
Name:BERNARD, MANDYSON
Entity Type:Individual
Prefix:
First Name:MANDYSON
Middle Name:
Last Name:BERNARD
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 1:512 BLUE WATER CT
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-9171
Mailing Address - Country:US
Mailing Address - Phone:321-216-8180
Mailing Address - Fax:
Practice Address - Street 1:4727 W IRLO BRONSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-5326
Practice Address - Country:US
Practice Address - Phone:407-978-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician