Provider Demographics
NPI:1831269620
Name:KOVEN, BERNARD JEROME
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:JEROME
Last Name:KOVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:SUITE 110-8
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-269-5515
Mailing Address - Fax:631-254-2470
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 110-8
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-269-5515
Practice Address - Fax:631-254-2470
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR016795-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN46681Medicare ID - Type UnspecifiedSOCIAL WORK