MEDICARE: MR. KEITH L HERBERT 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	R024623-1	NY

General Provider Information

NPI Number	:	1679644140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH L HERBERT LCSW

Provider Business Mailing Address
First Line	:	151 ALDA DR
Second Line	:
City	:	KINGSTON
State	:	NY
Zip	:	12401-8702
Country	:	US
Telephone Number	:	845-339-1020
Fax Number	:	845-339-2370

Provider Business Practice Location Address
First Line	:	49 MAIN ST
Second Line	:
City	:	ROSENDALE
State	:	NY
Zip	:	12472
Country	:	US
Telephone Number	:	845-658-9760
Fax Number	:

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

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	07/08/2007

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