Provider Demographics
NPI:1144722596
Name:BERGMAN, BARUCH (RADT)
Entity type:Individual
Prefix:
First Name:BARUCH
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 S GARTH AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-1570
Mailing Address - Country:US
Mailing Address - Phone:347-526-6124
Mailing Address - Fax:
Practice Address - Street 1:2010 S GARTH AVE APT 11
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1570
Practice Address - Country:US
Practice Address - Phone:347-526-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-13
Deactivation Date:2018-03-01
Deactivation Code:
Reactivation Date:2018-03-13
Provider Licenses
StateLicense IDTaxonomies
CAR1291520218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)