Provider Demographics
NPI:1659541324
Name:BERGEN PSYCHOTHERAPY & COMMUNITY OUTREACH, LLC
Entity Type:Organization
Organization Name:BERGEN PSYCHOTHERAPY & COMMUNITY OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALIDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMINIANNI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-833-8838
Mailing Address - Street 1:901 TEANECK RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4511
Mailing Address - Country:US
Mailing Address - Phone:201-357-2714
Mailing Address - Fax:
Practice Address - Street 1:901 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4511
Practice Address - Country:US
Practice Address - Phone:201-357-2714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052492001041C0700X
NJ44SC053229001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty