1174819874 NPI number — BERGEN PSYCHOLOGICAL SERVICES, INC.

Table of content: (NPI 1174819874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174819874 NPI number — BERGEN PSYCHOLOGICAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERGEN PSYCHOLOGICAL SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174819874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4015 N DRAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60618-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-512-4656
Provider Business Mailing Address Fax Number:
844-673-6162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 E. WASHINGTON
Provider Second Line Business Practice Location Address:
SUITE 1206
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-512-4656
Provider Business Practice Location Address Fax Number:
312-254-3172
Provider Enumeration Date:
06/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BERGEN
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
J.-S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-512-4656

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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