Provider Demographics
NPI:1821180225
Name:BERGMAN, MARVIN E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:E
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ARLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1710
Mailing Address - Country:US
Mailing Address - Phone:914-937-6699
Mailing Address - Fax:914-937-2713
Practice Address - Street 1:7 ARLINGTON PL
Practice Address - Street 2:
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-1710
Practice Address - Country:US
Practice Address - Phone:914-937-6699
Practice Address - Fax:914-937-2713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005543-1103T00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
V17941Medicare ID - Type UnspecifiedMEDICARE