Provider Demographics
NPI:1003981713
Name:BERGMAN, LESA GAIL (LPC)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:GAIL
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CENTRE ON THE LK
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1370
Mailing Address - Country:US
Mailing Address - Phone:636-699-2165
Mailing Address - Fax:
Practice Address - Street 1:206 CENTRE ON THE LK
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1370
Practice Address - Country:US
Practice Address - Phone:636-699-2165
Practice Address - Fax:636-625-1633
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001029221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498442706Medicaid
89520OtherNATIONAL BOARD FOR CERT C