Provider Demographics
NPI:1922195908
Name:BJELLAND, RICHARD (MSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:BJELLAND
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1920
Mailing Address - Country:US
Mailing Address - Phone:631-472-0036
Mailing Address - Fax:631-472-0036
Practice Address - Street 1:206 DEER PARK AVE.
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-1920
Practice Address - Country:US
Practice Address - Phone:631-472-0036
Practice Address - Fax:631-472-0036
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0297471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY45952OtherUNITED BEHAVIORAL HEALTH
NY0018541OtherVALUE OPTIONS
NY02128398Medicaid
NY0018541OtherGHI
N0L741Medicare UPIN
68829Medicare PIN