Provider Demographics
NPI:1215562434
Name:BERROUET, IMMACULA (MENTAL HEALTH PR)
Entity type:Individual
Prefix:MS
First Name:IMMACULA
Middle Name:
Last Name:BERROUET
Suffix:
Gender:F
Credentials:MENTAL HEALTH PR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3303
Mailing Address - Country:US
Mailing Address - Phone:917-971-4567
Mailing Address - Fax:
Practice Address - Street 1:7649 HEWLETT ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1429
Practice Address - Country:US
Practice Address - Phone:212-338-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool