Provider Demographics
NPI:1831303130
Name:PEMBERTON, REGINA M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:M
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1129
Mailing Address - Country:US
Mailing Address - Phone:516-972-3556
Mailing Address - Fax:
Practice Address - Street 1:29 BARSTOW RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2209
Practice Address - Country:US
Practice Address - Phone:516-972-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0713441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical