Healthcare Provider Details

I. General information

NPI: 1063567287
Provider Name (Legal Business Name): BARBARA BERGEN MINTZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 BLOOMFIELD AVE
CALDWELL NJ
07006-5166
US

IV. Provider business mailing address

11 KNOLLWOOD TER
CALDWELL NJ
07006-5808
US

V. Phone/Fax

Practice location:
  • Phone: 12-618-1705
  • Fax:
Mailing address:
  • Phone: 201-618-1705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number842413
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: