Provider Demographics
NPI:1912368580
Name:BERMEJO, BICENTE
Entity Type:Individual
Prefix:
First Name:BICENTE
Middle Name:
Last Name:BERMEJO
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 1:1400 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-4109
Mailing Address - Country:US
Mailing Address - Phone:209-631-9093
Mailing Address - Fax:
Practice Address - Street 1:2222 M ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3729
Practice Address - Country:US
Practice Address - Phone:209-385-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1301032105101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)