Provider Demographics
NPI:1104921790
Name:CERVERA, NEIL J (LCSW, PHD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:J
Last Name:CERVERA
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1716
Mailing Address - Country:US
Mailing Address - Phone:518-458-8162
Mailing Address - Fax:518-435-9436
Practice Address - Street 1:902 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1716
Practice Address - Country:US
Practice Address - Phone:518-458-8162
Practice Address - Fax:518-435-9436
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR015087-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01563386Medicaid
NY52170BMedicare ID - Type Unspecified