Provider Demographics
NPI:1902389463
Name:BERGOLD, DOROTHY JOAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:JOAN
Last Name:BERGOLD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 HERSAM ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2441
Mailing Address - Country:US
Mailing Address - Phone:781-438-9006
Mailing Address - Fax:
Practice Address - Street 1:385 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3033
Practice Address - Country:US
Practice Address - Phone:781-485-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105125261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care