MEDICARE: JOEL BERGMAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	MH9474	FL

General Provider Information

NPI Number	:	1689943482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL BERGMAN

Provider Business Mailing Address
First Line	:	4612 N 56TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-7123
Country	:	US
Telephone Number	:	813-367-2317
Fax Number	:	813-367-2312

Provider Business Practice Location Address
First Line	:	3107 N 50TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-2302
Country	:	US
Telephone Number	:	813-367-2317
Fax Number	:	813-367-2312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	12/22/2011

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