Provider Demographics
NPI:1457697807
Name:ROSENBERG, NICHOLAS DAVID (LCSW)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DAVID
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 DOMINGO AVE # 157
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2454
Mailing Address - Country:US
Mailing Address - Phone:917-702-6633
Mailing Address - Fax:
Practice Address - Street 1:1918 BONITA AVENUE, SECOND FLOOR
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:917-702-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0851331104100000X
CA767081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300124127Medicare PIN