Active NPI
Nicholas Ruben Debernardi, PH. D.
- Clinical Psychologist
- Jenison, MI
National Provider Identifier
1164768065
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 6301015230
- Practice address
- 1836 Baldwin St
Jenison, MI 49428-8901 - Phone
- (616) 457-0016
- Fax
- (616) 457-1950
- NPI assigned
- Dec 20, 2012
- Last updated
- Dec 20, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 6301015230 | MI | Primary |
Addresses
Primary practice location
1836 Baldwin St
Jenison, MI 49428-8901
Mailing address
1836 Baldwin St
Jenison, MI 49428-8901
Phone (616) 457-0016
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6301015230 | MI | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1355961600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1355961600000",
"number": "1164768065",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1836 BALDWIN ST",
"city": "JENISON",
"state": "MI",
"postal_code": "494288901",
"telephone_number": "616-457-0016",
"fax_number": "616-457-1950"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1836 BALDWIN ST",
"city": "JENISON",
"state": "MI",
"postal_code": "494288901",
"telephone_number": "616-457-0016",
"fax_number": "616-457-1950"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DEBERNARDI",
"first_name": "NICHOLAS",
"middle_name": "RUBEN",
"name_prefix": "Dr.",
"credential": "PH. D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-12-20",
"last_updated": "2012-12-20",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MI",
"license": "6301015230",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jenison, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.