Provider Demographics
NPI:1912633249
Name:BERMUDEZ, TAISHA
Entity Type:Individual
Prefix:
First Name:TAISHA
Middle Name:
Last Name:BERMUDEZ
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 1:9826 VICKIE PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1913
Mailing Address - Country:US
Mailing Address - Phone:314-357-5125
Mailing Address - Fax:
Practice Address - Street 1:9826 VICKIE PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1913
Practice Address - Country:US
Practice Address - Phone:314-357-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC14389951171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO171400000XMedicaid