Provider Demographics
NPI:1902873268
Name:BERNARD, SHAD THEODORE (MA, ATC/L)
Entity Type:Individual
Prefix:MR
First Name:SHAD
Middle Name:THEODORE
Last Name:BERNARD
Suffix:
Gender:M
Credentials:MA, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5077 TEWKESBURY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-3752
Mailing Address - Country:US
Mailing Address - Phone:937-237-1018
Mailing Address - Fax:937-439-6240
Practice Address - Street 1:1997 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3811
Practice Address - Country:US
Practice Address - Phone:937-401-6400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-001528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist