Healthcare Provider Details

I. General information

NPI: 1548174816
Provider Name (Legal Business Name): COLLEEN MARIE BERGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 215TH PL APT 3A
BAYSIDE NY
11361-3428
US

IV. Provider business mailing address

4643 215TH PL APT 3A
BAYSIDE NY
11361-3428
US

V. Phone/Fax

Practice location:
  • Phone: 718-683-6779
  • Fax:
Mailing address:
  • Phone: 718-683-6779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number113899
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: