Provider Demographics
NPI:1639159338
Name:BERNTSON, MARY LYNN (OTRL CHT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:BERNTSON
Suffix:
Gender:F
Credentials:OTRL CHT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:FLORENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:701-732-2947
Mailing Address - Fax:701-732-2945
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4040
Practice Address - Country:US
Practice Address - Phone:701-746-7521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100966225X00000X
AA522599225X00000X
ND25225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
24561OtherNORIDIAN MUTUAL
MN341M0BEOtherBC/BS
24561OtherBCBS ND
HP62219OtherHEALTH PARTNERS
2605838OtherUNITED HEALTH CARE
64-05705OtherMEDICA
24780OtherDEMERS LOCATION
ND54901Medicaid
MN201942600OtherMEDICAL ASSISTANCE
1042277OtherPREFERRED ONE
MN341M0BEOtherBC/BS
24561OtherNORIDIAN MUTUAL
24561Medicare ID - Type Unspecified