Provider Demographics
NPI:1245595511
Name:ROSTAD, BERIT (PD)
Entity Type:Individual
Prefix:
First Name:BERIT
Middle Name:
Last Name:ROSTAD
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10159-0139
Mailing Address - Country:US
Mailing Address - Phone:608-225-0569
Mailing Address - Fax:
Practice Address - Street 1:175 REMSEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4333
Practice Address - Country:US
Practice Address - Phone:608-225-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1178626103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool