Healthcare Provider Details

I. General information

NPI: 1295255149
Provider Name (Legal Business Name): BERGEN PSYCHIATRIC CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N MAPLE AVE STE 104
RIDGEWOOD NJ
07450-3233
US

IV. Provider business mailing address

65 N MAPLE AVE STE 104
RIDGEWOOD NJ
07450-3233
US

V. Phone/Fax

Practice location:
  • Phone: 201-956-9483
  • Fax: 201-288-5262
Mailing address:
  • Phone: 201-956-9483
  • Fax: 201-288-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MINI THOMAS
Title or Position: CCRP
Credential: MBBS
Phone: 201-956-9483