Provider Demographics
NPI:1073120432
Name:THE THERAPY ROOM MIND HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:THE THERAPY ROOM MIND HEALTH AND WELLNESS LLC
Other - Org Name:THE THERAPY ROOM MIND HEALTH AND WELLNESS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:352-362-6141
Mailing Address - Street 1:2581 HUNTCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4902
Mailing Address - Country:US
Mailing Address - Phone:850-520-3321
Mailing Address - Fax:850-848-6490
Practice Address - Street 1:2581 HUNTCLIFF LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4902
Practice Address - Country:US
Practice Address - Phone:850-520-3321
Practice Address - Fax:850-848-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110722500Medicaid