Provider Demographics
NPI:1962611053
Name:BERHANU, ENGEDAW (LCSW)
Entity type:Individual
Prefix:
First Name:ENGEDAW
Middle Name:
Last Name:BERHANU
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 1:3788 PINTAIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509
Mailing Address - Country:US
Mailing Address - Phone:925-522-0887
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE 125C
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605
Practice Address - Country:US
Practice Address - Phone:510-383-5095
Practice Address - Fax:510-383-5117
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 159801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical