Healthcare Provider Details

I. General information

NPI: 1477085892
Provider Name (Legal Business Name): BRANDON BJERTNES LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 LAKESIDE DR
OAKDALE NY
11769-2148
US

IV. Provider business mailing address

166 LAKESIDE DR
OAKDALE NY
11769-2148
US

V. Phone/Fax

Practice location:
  • Phone: 631-375-5352
  • Fax:
Mailing address:
  • Phone: 631-375-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007188
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: