Provider Demographics
NPI:1235344508
Name:LA MOTTA, BERENICE S (LSW)
Entity Type:Individual
Prefix:MRS
First Name:BERENICE
Middle Name:S
Last Name:LA MOTTA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2339
Mailing Address - Country:US
Mailing Address - Phone:973-429-9440
Mailing Address - Fax:
Practice Address - Street 1:142-10 SANFORD AVENUE
Practice Address - Street 2:ANNEX 1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-463-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05335400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker