Basic Information
| Provider Information | |||||||||
| NPI: | 1851626485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNARD | ||||||||
| FirstName: | KONAH | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14409 GREENVIEW DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207083293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
| FaxNumber: | 3014980009 | ||||||||
| Practice Location | |||||||||
| Address1: | 14409 GREENVIEW DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207083293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
| FaxNumber: | 3014980009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 05866 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05866 | 01 | MD | MARYLAND BOARD OF OCCUPATIONAL THERAPY PRACTICE | OTHER |