Provider Demographics
NPI:1164255881
Name:MITTLEBERG, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MITTLEBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1004
Mailing Address - Country:US
Mailing Address - Phone:516-477-7733
Mailing Address - Fax:
Practice Address - Street 1:100 W 57TH ST APT 19L
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3328
Practice Address - Country:US
Practice Address - Phone:516-477-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst