Provider Demographics
NPI:1689943482
Name:BERGMAN, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BERGMAN
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 1:4612 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-7123
Mailing Address - Country:US
Mailing Address - Phone:813-367-2317
Mailing Address - Fax:813-367-2312
Practice Address - Street 1:3107 N 50TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-2302
Practice Address - Country:US
Practice Address - Phone:813-367-2317
Practice Address - Fax:813-367-2312
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9474101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)