Provider Demographics
NPI:1083703219
Name:BERGSTROM, CANDEE LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CANDEE
Middle Name:LYNN
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6848 BIXBY LN.
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838
Mailing Address - Country:US
Mailing Address - Phone:804-590-9206
Mailing Address - Fax:
Practice Address - Street 1:8200 AVE. B
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1717
Practice Address - Country:US
Practice Address - Phone:804-734-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904006409101YM0800X
NCC005383101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health