MEDICARE: NIA BERT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	089796	NY

General Provider Information

NPI Number	:	1053065938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIA BERT LCSW

Provider Business Mailing Address
First Line	:	4470 21ST ST # 3137
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4470 21ST ST # 3137
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5114
Country	:	US
Telephone Number	:	929-486-2098
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2022
Last Update Date	:	02/09/2022

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