=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356482343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBBERENBERG PSYCHOLOGICAL SERVICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 482 2ND ST SUITE #1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-768-2461
-----------------------------------------------------
Fax | 718-768-2461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 86 PROSPECT PARK W
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-3575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-768-2461
-----------------------------------------------------
Fax | 718-768-2461
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARTIN BERENBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-768-2461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 005885
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------