Provider Demographics
NPI:1700245651
Name:PEMBERTON, LESA (LMSW)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WYONA ST
Mailing Address - Street 2:24
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2543
Mailing Address - Country:US
Mailing Address - Phone:917-593-0356
Mailing Address - Fax:
Practice Address - Street 1:110 WYONA ST
Practice Address - Street 2:24
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2543
Practice Address - Country:US
Practice Address - Phone:917-593-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081705-1251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health