Healthcare Provider Details

I. General information

NPI: 1952708968
Provider Name (Legal Business Name): DOCTHOR P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 2ND AVE. SUITE 310
NEEDHAM MA
02494
US

IV. Provider business mailing address

75 2ND AVE. SUITE 310
NEEDHAM MA
02494
US

V. Phone/Fax

Practice location:
  • Phone: 781-726-6698
  • Fax: 617-326-8314
Mailing address:
  • Phone: 781-726-6698
  • Fax: 617-326-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number204123
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number204123
License Number StateMA

VIII. Authorized Official

Name: DR. THOR CHRISTIAN BERGERSEN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 781-726-6698