Healthcare Provider Details

I. General information

NPI: 1275526824
Provider Name (Legal Business Name): JOHN B. PEMBER LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 DELAWARE AVE
DELMAR NY
12054-1227
US

IV. Provider business mailing address

196 DELAWARE AVE
DELMAR NY
12054-1227
US

V. Phone/Fax

Practice location:
  • Phone: 518-439-0033
  • Fax: 518-439-7167
Mailing address:
  • Phone: 518-439-0033
  • Fax: 518-439-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR021467-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: