Provider Demographics
NPI:1548388127
Name:ETROG, NATHAN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:ETROG
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 1:83 CAYUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3645
Practice Address - Country:US
Practice Address - Phone:718-869-8822
Practice Address - Fax:718-869-8829
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR 011933104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR011933OtherNYS DEPT. OF ED. LICENSE
NYR011933OtherNYS DEPT. OF ED. LICENSE
NYQ30927Medicare UPIN