Healthcare Provider Details

I. General information

NPI: 1508289224
Provider Name (Legal Business Name): BERGEN PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 STATE ST STE 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: 201-342-4004
  • Fax: 201-342-4208
Mailing address:
  • Phone: 845-821-2605
  • Fax: 201-243-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberMA65065
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier7492201
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MR. MOHSAN JAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 845-821-2605