Healthcare Provider Details

I. General information

NPI: 1043562705
Provider Name (Legal Business Name): PARK SLOPE CREATIVE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 5TH ST
BROOKLYN NY
11215-2806
US

IV. Provider business mailing address

20 KINGS MILL RD
MONROE NJ
08831-8902
US

V. Phone/Fax

Practice location:
  • Phone: 917-941-2652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074666
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000302
License Number StateNY

VIII. Authorized Official

Name: MARYGRACE BERBERIAN
Title or Position: PRESIDENT
Credential: ATR-BC, LCSW, LCAT
Phone: 917-941-2652