Provider Demographics
NPI:1801521414
Name:BERNARDY, ELIZABETH ANN (CM II)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:BERNARDY
Suffix:
Gender:F
Credentials:CM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:1115 HAR-BER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:918-796-4435
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHA-R-2935171M00000X
OR22-CRM-114175T00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2733121OtherODL
OR500808956Medicaid
ORTHW107282OtherPEER SUPPORT -ADULT ADDICTIONS