=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285985812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERENA DYAN WASSERSTEIN ATR-BC, LCAT, ACSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2012
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 N 12TH ST FL 7
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-883-6454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 47
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92038-0047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-883-6454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 129132
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | 001240
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------