| Doctor Name: | DR. NICHOLAS RUBEN DEBERNARDI |
| NPI Number: | 1164768065 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH. D. |
| License Number: | 6301015230 |
| Business Practice Address: | 1836 Baldwin St Jenison, MI - 494288901 |
| Business Phone Number: | 6164570016 |
| Business Fax Number: | 6164571950 |
| Mailing Address: | 1836 Baldwin St, JENISON |
| State: | MI |
| Postal Code: | 494288901 |
| Phone Number: | 6164570016 |
| Fax Number: | 6164571950 |
| NPI Enumeration Date: | 12/20/2012 |
| NPI Last Update Date: | 12/20/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6301015230 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |