Provider Demographics
NPI:1558697433
Name:CERBERVILLE, MARK (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:CERBERVILLE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5241
Mailing Address - Country:US
Mailing Address - Phone:845-790-9011
Mailing Address - Fax:845-692-7125
Practice Address - Street 1:2001 ROUTE 17M
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-5241
Practice Address - Country:US
Practice Address - Phone:845-790-9011
Practice Address - Fax:845-692-7125
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032827-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker