Provider Demographics
NPI:1124215207
Name:BERGMAN, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:BERGMAN
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 1:1 LOIS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4404
Mailing Address - Country:US
Mailing Address - Phone:203-221-8893
Mailing Address - Fax:203-229-0499
Practice Address - Street 1:1 LOIS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4404
Practice Address - Country:US
Practice Address - Phone:203-221-8893
Practice Address - Fax:203-229-0499
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT92911041C0700X
NY0790821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400060109Medicare PIN