Healthcare Provider Details

I. General information

NPI: 1922195908
Provider Name (Legal Business Name): RICHARD BJELLAND MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 DEER PARK AVE.
BABYLON NY
11704-1920
US

IV. Provider business mailing address

704 MIDDLE RD
BAYPORT NY
11705-1920
US

V. Phone/Fax

Practice location:
  • Phone: 631-472-0036
  • Fax: 631-472-0036
Mailing address:
  • Phone: 631-472-0036
  • Fax: 631-472-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR029747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: