Healthcare Provider Details

I. General information

NPI: 1578117982
Provider Name (Legal Business Name): BERTA KHOLI MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 E 15TH ST
BROOKLYN NY
11230-6702
US

IV. Provider business mailing address

1552 E 15TH ST
BROOKLYN NY
11230-6702
US

V. Phone/Fax

Practice location:
  • Phone: 718-759-8982
  • Fax:
Mailing address:
  • Phone: 718-759-8982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1242101181
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number003326
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: