Provider Demographics
NPI:1518312875
Name:BERGEN, THOMAS JR (LSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BERGEN
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DEVOE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-1939
Mailing Address - Country:US
Mailing Address - Phone:732-710-6319
Mailing Address - Fax:
Practice Address - Street 1:11 DEVOE ST
Practice Address - Street 2:
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-1939
Practice Address - Country:US
Practice Address - Phone:732-710-6319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05986800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker