Provider Demographics
NPI:1326262163
Name:WEIDBERG, CAROL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:WEIDBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:DELLO RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:125-10 QUEENS BLVD
Mailing Address - Street 2:APT 2405
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415
Mailing Address - Country:US
Mailing Address - Phone:718-544-3454
Mailing Address - Fax:
Practice Address - Street 1:110-20 71ST AVE
Practice Address - Street 2:PROFESSIONAL OFFICE #3
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-544-3454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR119051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
337986OtherVALUE OPTIONS