Provider Demographics
NPI:1609434315
Name:MILLS, BERETA
Entity Type:Individual
Prefix:
First Name:BERETA
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 VAN SICLEN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-4347
Mailing Address - Country:US
Mailing Address - Phone:347-737-0942
Mailing Address - Fax:
Practice Address - Street 1:946 E 211TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-1108
Practice Address - Country:US
Practice Address - Phone:718-547-0133
Practice Address - Fax:718-547-0051
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34255101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)