Provider Demographics
NPI:1447862446
Name:RENE, NEILA BERTHE
Entity type:Individual
Prefix:
First Name:NEILA
Middle Name:BERTHE
Last Name:RENE
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 1:15 LONGWORTH AVE UNIT 223
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7086
Mailing Address - Country:US
Mailing Address - Phone:617-735-5818
Mailing Address - Fax:
Practice Address - Street 1:15 LONGWORTH AVE UNIT 223
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7086
Practice Address - Country:US
Practice Address - Phone:617-735-5818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoula
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty