MEDICARE: BERGEN PSYCHOLOGICAL SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1174819874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERGEN PSYCHOLOGICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	4525 N RAVENSWOOD AVE STE 202
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-8038
Country	:	US
Telephone Number	:	312-870-0500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 N RAVENSWOOD AVE STE 202
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-8038
Country	:	US
Telephone Number	:	312-870-0500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEREMIAH BERGEN
Credential	:	MS
Telephone Number	:	312-600-7371

Provider Enumeration Date	:	06/22/2011
Last Update Date	:	06/11/2026

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