Healthcare Provider Details

I. General information

NPI: 1306126792
Provider Name (Legal Business Name): BERGEN PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 STATE ST SUITE# 2
HACKENSACK NJ
07601-5515
US

IV. Provider business mailing address

PO BOX 809
TEANECK NJ
07666-0809
US

V. Phone/Fax

Practice location:
  • Phone: 201-833-5791
  • Fax: 201-243-7874
Mailing address:
  • Phone: 201-833-5791
  • Fax: 201-243-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number25MA06506500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MOHSAN JAN
Title or Position: ADMINISTRTOR
Credential:
Phone: 201-833-5791