Provider Demographics
NPI:1154501682
Name:DOUGLAS A. BERGSTROM, PH.D., PLLC
Entity Type:Organization
Organization Name:DOUGLAS A. BERGSTROM, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-445-3835
Mailing Address - Street 1:143 E MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2028
Mailing Address - Country:US
Mailing Address - Phone:928-445-3835
Mailing Address - Fax:928-445-7071
Practice Address - Street 1:143 E MERRITT ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2028
Practice Address - Country:US
Practice Address - Phone:928-445-3835
Practice Address - Fax:928-445-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1142251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health