Provider Demographics
NPI:1912010745
Name:BERKOVITZ, DAVID L (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:BERKOVITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 FRANKLIN AVE
Mailing Address - Street 2:208
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110
Mailing Address - Country:US
Mailing Address - Phone:888-299-9432
Mailing Address - Fax:973-472-1305
Practice Address - Street 1:349 FRANKLIN AVE
Practice Address - Street 2:208
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:888-299-9432
Practice Address - Fax:973-472-1305
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ03119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00079084OtherMCARE RR
437638Medicare ID - Type Unspecified