Provider Demographics
NPI:1144743022
Name:BERGEN, KATHLEEN RUTH (MFT-I)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:RUTH
Last Name:BERGEN
Suffix:
Gender:F
Credentials:MFT-I
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:RUTH
Other - Last Name:CHAVOOR-BERGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT-I
Mailing Address - Street 1:1141 W SHAW AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3713
Mailing Address - Country:US
Mailing Address - Phone:559-449-2730
Mailing Address - Fax:
Practice Address - Street 1:1141 W SHAW AVE STE 203
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3713
Practice Address - Country:US
Practice Address - Phone:559-449-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20546103T00000X
CAPSCY20546103TC0700X
CA99895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical