Provider Demographics
NPI:1194990150
Name:ROBERTA BERNITT
Entity type:Organization
Organization Name:ROBERTA BERNITT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:PROF
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNITT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:917-558-5355
Mailing Address - Street 1:6730 CLYDE ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4055
Mailing Address - Country:US
Mailing Address - Phone:917-558-5355
Mailing Address - Fax:718-520-0671
Practice Address - Street 1:67-30 CLYDE ST. -SUITE A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:917-558-5355
Practice Address - Fax:718-520-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047904302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145602Medicaid