Provider Demographics
NPI:1134304629
Name:BERGNER, RAYMOND MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:BERGNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4200
Mailing Address - Country:US
Mailing Address - Phone:309-828-6821
Mailing Address - Fax:
Practice Address - Street 1:901 E GROVE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4200
Practice Address - Country:US
Practice Address - Phone:309-828-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical