Healthcare Provider Details

I. General information

NPI: 1831491497
Provider Name (Legal Business Name): JON BERCOVICI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 SUMMIT AVE
HACKENSACK NJ
07601-8562
US

IV. Provider business mailing address

185 PROSPECT AVE APT 14 I
HACKENSACK NJ
07601-2210
US

V. Phone/Fax

Practice location:
  • Phone: 201-546-7425
  • Fax:
Mailing address:
  • Phone: 201-446-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00020000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: