Provider Demographics
NPI:1073725545
Name:BERGMAN, LINDA SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:SUSAN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:SUSAN
Other - Last Name:BERGMAN-ZENTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:83 STONY HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1750
Mailing Address - Country:US
Mailing Address - Phone:631-754-4567
Mailing Address - Fax:631-754-2707
Practice Address - Street 1:83 STONY HOLLOW ROAD
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1750
Practice Address - Country:US
Practice Address - Phone:631-754-4567
Practice Address - Fax:631-754-2707
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004927-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAF00096OtherMDNY
NYV69371Medicare ID - Type Unspecified