Provider Demographics
NPI:1336217397
Name:BERK, MITCHELL (LCSW, MA)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:BERK
Suffix:
Gender:M
Credentials:LCSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18417 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1729
Mailing Address - Country:US
Mailing Address - Phone:718-454-0177
Mailing Address - Fax:718-454-1819
Practice Address - Street 1:18417 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1729
Practice Address - Country:US
Practice Address - Phone:718-454-0177
Practice Address - Fax:718-454-1819
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043964-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical