Provider Demographics
NPI:1952459646
Name:BERNSTEIN, PHYLLIS MAY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:MAY
Last Name:BERNSTEIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CHANNING RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1115
Mailing Address - Country:US
Mailing Address - Phone:617-969-4255
Mailing Address - Fax:508-473-6644
Practice Address - Street 1:1689 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4434
Practice Address - Country:US
Practice Address - Phone:617-264-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10314541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABEP22528Medicare ID - Type Unspecified