Provider Demographics
NPI:1295255149
Name:BERGEN PSYCHIATRIC CARE LLC
Entity type:Organization
Organization Name:BERGEN PSYCHIATRIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCRP
Authorized Official - Prefix:
Authorized Official - First Name:MINI
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MBBS
Authorized Official - Phone:201-956-9483
Mailing Address - Street 1:65 N MAPLE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3233
Mailing Address - Country:US
Mailing Address - Phone:201-956-9483
Mailing Address - Fax:201-288-5262
Practice Address - Street 1:65 N MAPLE AVE STE 104
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3233
Practice Address - Country:US
Practice Address - Phone:201-956-9483
Practice Address - Fax:201-288-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09523700OtherSTATE LICENCE