Healthcare Provider Details

I. General information

NPI: 1366894321
Provider Name (Legal Business Name): BETHANIE SHANA BERSON RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 OCEAN PARKWAY ROOM 416
BROOKLYN NY
11235
US

IV. Provider business mailing address

2601 OCEAN PARKWAY ROOM 416
BROOKLYN NY
11235
US

V. Phone/Fax

Practice location:
  • Phone: 718-616-5373
  • Fax: 718-616-5444
Mailing address:
  • Phone: 718-616-5373
  • Fax: 718-616-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number694643
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number40 402093
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: