Provider Demographics
NPI:1720504913
Name:BERNARDIN, SAVANNAH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:BERNARDIN
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 1:24 CLEEVE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-6041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1577 CONGRESS ST STE 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23252225100000X
MEPT5914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist