Provider Demographics
NPI:1174819874
Name:BERGEN PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:BERGEN PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:BERGEN COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J-S
Authorized Official - Last Name:BERGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-512-4656
Mailing Address - Street 1:4015 N DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2219
Mailing Address - Country:US
Mailing Address - Phone:773-512-4656
Mailing Address - Fax:844-673-6162
Practice Address - Street 1:25 E. WASHINGTON
Practice Address - Street 2:SUITE 1206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:773-512-4656
Practice Address - Fax:312-254-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100135195Medicare PIN