Provider Demographics
NPI:1275526824
Name:PEMBER, JOHN B (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:B
Last Name:PEMBER
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1227
Mailing Address - Country:US
Mailing Address - Phone:518-439-0033
Mailing Address - Fax:518-439-7167
Practice Address - Street 1:196 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1227
Practice Address - Country:US
Practice Address - Phone:518-439-0033
Practice Address - Fax:518-439-7167
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR021467-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01715411Medicaid
NYR90086Medicare UPIN
NY01715411Medicaid